Yes, it’s possible.

HI Dr Mauskop … I have tried several treatments for my migraine including CGRP based. Something interesting and simple that has worked is “dry needling” to reduce tension in my shoulders. Along with daily triptan, regular dry needling sessions have kept my migraines in check for most part and reduced intensity of pain has been a gift. Do you think it is possible that with regular physiotherapy sessions the frequency of triptan intake can be reduced?

You can refer your doctors to my blog posts.

Would it be unreasonable for me to ask for medical research backing up reasons my new doctors are afraid of daily use or frequent use of triptans before agreeing to start trying other maintenance drug treatments? Aside from the chronic nature of migraines, my health is quite good. I do have asthma, and mild atrial valve regurgitation but that’s it as far as other health issues. My pulmonologist and cardiologist don’t have a problem with my frequent/daily use of triptans.

Unfortunately, I cannot answer specific questions since I don’t have enough information.

Yes, it is definitely of benefit for some patients, otherwise the FDA would not have approved it.

Dear Dr. Mauskop, I suffered chronic migraine for apprx. 13 years and managed them without any problems with daily triptans. I took mainly generic sumatriptan daily with no side effects and got very good control of them. Last year I suddenly got better and was only having a couple migraines a month. Then about a month ago I had a month long illness that resulted in multiple trips to ER and no clear diagnosis. I had a CT scan of my brain to rule out tumor or stroke or anything serious. Nothing was found. Since recovering, I’m back to a more chronic migraine condition. Now however I have different doctors than I did when I was taking daily triptans and my new doctors have a problem with me taking triptans on a daily or near daily basis. They want me to try out other maintenance drugs. I personally do NOT want to try out any other drugs unless and until the triptans stop working or I develop side effects. Is there any good reason I should start playing around trying out other drugs when triptans work so well for me?

Hi Dr Mauskop .. Thanks for your reply. In my last post I mentioned that after failed Botox my doctor has suggested emgality. I find instead he wants to try vyepti. I was wondering in your experience have you known vyepti to be of any benefit for your migraine patients? Thank you again!

If two treatments did not produce even a little, Botox is not likely to help.
Emgality can be more effective than Aimovig.

Hi Dr Mauskop .. I have had two Botox treatments so far with no success at all in migraine reduction. In your experience more Botox treatments are needed to see results is some patients? What is your opinion on emgality? (I have tried Amovig with no success. Thank you!

You may want to try an online headache specialist at withcove.com

I am 50 years old and am in the late stage of perimenopause. It seems like the frequency and pain level of my headaches/migraines is in increasing with these huge fluctuations in hormones. I have my cycle every two weeks. I need to take my naratriptan every other day, but I can’t find anyone who will prescribe enough tablets.

Ambien and similar drugs are good for short periods of time. Long-term use has been associated with cognitive problems. I recommend my patients following sleep hygiene, melatonin in small amounts (300 mcg), and cognitive-behavioral therapy (CBT). You can access CBT for free at ThisWayUp.org.au.

I just bought and read your book. I found you through the Migraine World Summit. I also need triptans more than is ‘recommended’ and I always go ‘cold turkey’ around the third day, often taking a sleeping pill hoping to wake up with out a migraine. What is your opinion on. Ambien for sleep hoping to wake up migraine free? Thank you.

do you recommend to hold on tp hormonal therapy as long as we can if we are pre menaposal. the migraine is going more and more as i get close to menapouse but I do not want to ruin hormones as i tried to ease the migraine.

Only on rare occasions.

Do the brand name triptans work better than the generic medications?

I would ask your doctor about trying a different triptan and about Botox injections.

Hi there. I just found this site and have learned a lot from reading people’s questions and comments. I suffer from daily migraines, often needing to take Rizatriptan at 2 different times of the day about 12 hours apart. I don’t feel like Rizatriptan is working as well for me as it used to. My migraines have increased over the last 4-5 months from 15-18 a month to daily. I am peri-menopausal and my doctor recommended Depo Provera to shut down my ovaries and 1mg of Estradiol per day to level off estrogen in hopes that if my migraines are hormonal, this will control them. I am almost 4 weeks into this protocol and no change. I was told it could take 6-8 weeks for results. Any thoughts? I have tried Topiramate and Amitryptaline for prevention with no success. My quality of life has been dramatically affected. Any suggestions would be appreciated. Thank you!

Yes, propranolol is a good idea. It can help both tachycardia and migraines.

I have been taking sumatriptan since it came on the market and have daily migraine. Last spring I developed bouts of paroxysmal tachycardia. I can’t find a new doctor and so have been whisked to hospital three times via ambulance and have been tested several times for heart issues (ECG x 4, echo, Holter (48 hrs) as well as blood tests. I have to wait another three months to see an internist. I have been carrying on with taking 50 mg suma but only as treatment. Some days I will not get a migraine at all. I am 70.
Since I have this tachycardia, elevated heart rate and possibly POTS, but not an actual “ heart problem” should I get off the triptans? Not looking for personal medical advice. I am going to call a teleheath company to see if they can prescribe propranolol for me as I am super-anxious over this. I mentioned triptans to three doctors in various emergency depts and not one appeared to care. I live in Canada.

I am glad I found your book – I never knew there were so many treatment options and the fact that there is no hard evidence to suggest that triptans cause MOH is liberating.

I have had headaches for my entire life (I’m now 48), but was only diagnosed as having migraines after at about age 40. At that time I was put on a drug that, unbeknownst to me, had headache as a major side effect (Nexium). My headache frequency increased so I started to take large doses of ibuprofen and consumed large amounts of caffeine to help.

When I finally went to my internist with persistent daily headaches, he told me that I had MOH and that I had to stop all medications. The following three days were awful. The pain was excruciating but the frequency of the headaches did decrease. I stayed medication-free for about three months. During that time I had about 5 headaches each month, but they were intense.

Now I have about 10 or so mild hedaches month and take Nurtec qod and eletriptan. Eletriptan has been a life saver for me. Nurtec works OK, but eletriptan always stops the pain. My physician only prescribes 8-9 at a time but I hoard them so I have a pretty good stockpile. I never use caffeine anymore because I do think that caused a problem.

Dr. Mauskop (and others), I have had migraines for 30 years (ages 12-42) and used mostly Sumatriptan for relief in the past 20 years. The past 10 years it was rare for me to have a day without taking at least 20-50mg to alleviate the pain so I could work. I am off work now and trying to reduce usage through resting when able, coping in other ways, or simply enduring the pain. Fortunately, these efforts have led to a significant reduction in triptan use in the past month and none in the past week. Unfortunately, it might be adding to other mental issues. I have already developed anxiety and depression due in large part to growing hypersensitivities to light and sound, but all of these symptoms have worsened in the past month. Sumatriptan apparently has similarly affects to an SSRI in some ways, so is it likely for these symptoms to worsen when stopping/significantly reducing sumatriptan. Is it also possible for sumatriptan chronic use to contribute to sensitivities to light and sound because it benefits it when treating a migraine but maybe it causing longer term harm by keeping the brain from being able to naturally handle such stressors/stimuli? Either way, is it likely for any “withdrawal” effects from sumatriptan to eventually work themselves out? How long does it typically take after stopping sumatriptan? Thanks

All I can say is that I have a few dozen patients like you.

Dear Dr. Mauskop, in addition to my migraines that I’ve had since I was 12, I’ve been waking up every day for years with a headache that only goes away with a triptan. It doesn’t matter where I sleep or what pillow I use. No abnormalities were found during a sleep study in the hospital. Can you say something about this? Thanks in advance!

This study again confirms that sumatriptan does not cause MOH or rebound headaches and in fact can help.

Hi Dr. Mauskop,

I was wondering if you saw this study and what your thoughts were. The participants took sumatriptan 25 mg/3 times day for 10 days in hopes of reducing daily sumatriptan use.

As always, thank you for being so generous with your knowledge and time.

Daily sumatriptan for detoxification from rebound
P Drucker 1, S Tepper
Affiliations expand
PMID: 15613182 DOI: 10.1046/j.1526-4610.1998.3809687.x
Abstract
Medications which provide symptomatic relief from headache can transform episodic migraine into chronic daily headache by propagating the daily headache, causing “rebound.” It is possible to restore the episodic migraine pattern by using an inpatient course of intravenous dihydroergotamine. This study was undertaken to explore whether it was possible to use oral sumatriptan in the outpatient setting as a bridge to detoxification for patients with chronic daily headache due to medication overuse. All patients had previously met International Headache Society (IHS) criteria for episodic migraine and currently had greater than 15 days of headache per month for greater than 1 month. These patients were advised to take 25 mg sumatriptan by mouth three times a day for 10 days or until they were headache-free for 24 hours. Results reveal that of the 26 patients who started the protocol, 58% had reverted to an episodic migraine pattern at 1 month, and 69% were no longer having chronic daily headache at 6 months. This study demonstrates that it is possible to detoxify patients with rebound headaches using oral sumatriptan during the withdrawal period in an outpatient setting.

YOu might be having sinus headaches in addition to migraines.

I have migraines that have changed in their location over the years. About 7 years ago, one of the locations of pain is the upper side of the nose. It will usually extend to the front of the eyebrow but the pain will not travel further. I take sumatriptan for migraines that occur in other locations and it’s very effective, but for the pain in the nasal/eyebrow area its effectiveness is less predictable. I have tried Sudafed (without Advil), Afrin nasal spray, Benadryl, and even had a septoplasty. None of these treatments have helped for this particular facial pain. Glad the combination of Advil/Sudafed is successful for the person who just posted. Will give this a try. Wondering if others have this very specific facial pain and what they have tried.

Dr Mauskop .. On a rainy day, and leading up to it 100% of the time I am getting pain one side of my nose. It does not seem to spread out to the head. Triptan does not seem to be effective there for on these situations but Advil Sudafed is. Triptan takes care of all other versions of Migraine I get. Can you please comment on that? Thanks!

Understood- I just want to thank you for this blog and also for taking the time to respond. You have helped me immeasurably just by presenting this information, one doctor made me feel like a drug addict for taking daily triptans and that was a terrible feeling. Thanks again.

That is not a simple question and also, I cannot give individual advice on the blog.

I meant I take Emgality monthly along with the daily triptan. For a while I didn’t need the triptans daily anymore while on the Emgality, but now I do, so I’m going to stop it. Just was wondering if I should bother trying one of the other ones.

It is not clear that Emgality and other similar drugs are any safer than a daily sumatriptan.

I’m thankful to have found this page, I take 50-100 mg daily of sumatriptan and have for years. I had some relief of daily meds with Emgality, but it isn’t really helping anymore. Do you think it is useful to try one of the other injectables? I also just ordered your book. Thank you.

Many vitamins stores sell it and it is also available on Amazon.

Dr Mauskop .. you mention Petadolex butterbur 150mg in your book. Do you know where one can buy it? Thanks!

Thank you very much for this info, Dr. Mauskop. I just bought your book. It is excellent and I remain hopeful. Your service to the headache community is hugely appreciated.

There does not seem to be an association between sumatriptan and gastro-esophageal reflux. The study you found was done in 13 healthy volunteers with an injection of sumatriptan. There are no reports of GERD in migraine sufferers. This does not mean that sumatriptan cannot cause GERD in some people, but this is not common.

Dear Doctor, I have had migraines since childhood. They are now in the region of 15-20 a month. I have been taking sumatriptan generic 15 – 20 times a month at 50mg dose. Recently, I have been swallowing a lot in the night and have developed GERD despite being slim and healthy. I just turned 70. There is a 1999 study [https://pubmed.ncbi.nlm.nih.gov/10566707/] saying that sumatriptan, as a 5HT1 agonist, relaxes the LES, allowing stomach acid to flow into the esophagus. I am not asking you to comment on my specific case. I am wondering how common GERD in association with sumatriptan use is, whether other chronic users have experienced it, and whether other triptans are less likely to exert this effect. Obviously, I am concerned about the development of Barratt’s esophagus or worse. Many thanks.

Not daily triptan will not offset the effect of any preventive treatment, including Aimovig.

Hey Dr, is daily triptan use (and potential overuse headache) likely to offset the effectiveness of a preventive treatment like Aimovig? or these preventive treatments can function effectively despite MoH?

No, unfortunately, there is no hard evidence for the existence of MOH caused by NSAIDs and triptans. We do have evidence for caffeine and opioids.

Hi,

I have been taking Sumatriptan for some years now. One of the doctors I see (it’s a community clinic) is insisting that I am suffering from MOH, however I disagree.
I have written to them and attached a link to this page for them to read.

They obviously don’t agree with it, as they are saying there is plenty of evidence supporting MOH.
They are now refusing to write a prescription for Sumatriptan for me.

I looked on the internet and there is a lot of information supporting MOH.
Here is the a link to the page I was looking at.

https://my.clevelandclinic.org/health/diseases/6170-medication-overuse-headaches

My question is, Is there or isn’t there evidence to actually prove this one way on another!?

Thanks
Lyndon

Magnesium can interfere with the absorption of Syntroid and they should be taken at least 4 hours apart.

Dr Mauskop… Does B2, Q10, Magnesium that I take for migraines can interfere with synthroid taken for hypothyroid. Thank You!

I take 50mg every day and I have been for over 10 years…it has made my life livable.

You may want to check out my new book, The End of Migraines: 150 Ways to Stop Your Pain. It answers your question about naltrexone and has a lot of other useful information.

Thank you. One more question – do you have any experience with or thoughts on the use of low-dose naltrexone for reducing headache/migraine frequency?

I have chronic migraine (20-25) migraines per month. I use Rizatriptan almost every day. I break a 10mg tablet in half and it usually gets rid of the migraine, but comes back the next day.
I also use the nasal steroid Nasacort. Is it possible that this is contributing to my chronic migraine?
I have been on it for years, when I try to get off of it my rhinitis comes back.

It does not

I’ve been taking rizatriptan for almost 10 years, usually between 10-12 days a month (sometimes as high as 16 days per month). I’m nervous that I have, or will develop, medication overuse headache. I can go periods of 6-10 days every month without needing a triptan, but I don’t know if that’s long enough to consider myself not in “rebound.” No preventatives have ever worked; the only thing that’s helped reduce my migraines over the years has been following the keto diet (which is hard to maintain). Does it sound like MOH to you?

It is not contraindicated unless Raynaud’s is very severe. It is an acute effect while sumatriptan is in circulation.

Is Sumatriptan contraindicated in patients with intermittent Raynaud’s? If so, would the effects of Sumatriptan on Raynaud’s be acute only while taking the medication, or could it cause a chronic worsening of Raynaud’s?

Thank you

No, I have not.

For people on long-term, almost daily use of Sumatriptan, have you heard of any neuromuscular symptoms or any other long-term symptoms?

Here is another article that raises concern about the use of acetaminophen (Tylenol) in pregnancy. And what is most relevant is that acetaminophen is ineffective for severe migraines and sumatriptan is.

Problems arise in 3% of pregnancies in healthy women on no medications. If a woman was taking prescription medicine, the obstetrician is at risk of a malpractice lawsuit. The neurologist or any other doctor who prescribes any drug is also in legal jeopardy. This is why no doctor will ever say that any drug (with few exceptions) is safe to take in pregnancy.

When a drug has been on the market for many years, we do get an idea of its safety. But even acetaminophen (Tylenol) that has been in use for many decades and are is considered safe by most doctors was recently found to increase the risk of ADHD.

Some of the safety information comes from pregnancy registries pharmaceutical companies set up for their products. GlaxoSmithKline also had such a registry for sumatriptan (Imitrex). It contains information on over 1,000 women who took sumatriptan while pregnant. This number is not sufficient to proclaim sumatriptan completely safe, but no serious effects on the fetus were detected. This is why I do prescribe sumatriptan in pregnancy.

I am trying to conceive, and giving myself an incredibly hard time about the sumatriptan I take – trying my best not to take it and often suffering massively as a result. My neurologist is quite vague about whether I can take sumatriptan when pregnant and I can’t find anything conclusive online myself. Are you aware of any recent studies since, like you say, the drug has been around for so many year now. Thank you.

It can be good and bad. An excessive strain of lifting heavy weights can trigger a migraine. Straining your neck muscles while weight lifting is another way some people trigger a migraine. On the other hand, regular exercise, including weight-lifting, has been proven to prevent migraines.

Is there any connection between working out with weights and migraine. Good or bad.

Yes, taking zinc and valerian starting a few days before the period could be sufficient.

I’ve just finished reading your new book and am eager to start implementing some of the non-drug strategies, including some supplementation of zinc and valerian. Your book said they work better together but I’m wondering if it is necessary to take them both daily as a preventive or just to treat acute attacks? If I’m specifically trying to prevent and treat menstrual migraines, would it be effective to just supplement the zinc and valerian leading up to and during my period? Thank you!

Yes, amitriptyline is one of the drugs used for the prevention of migraines. It can be combined with triptans but please ask your doctor about it.

Dr, for daily migraines is 50 mg Amitriptyline useful in decreasing the frequency of migraines? Can Triptan be taken while you are taking Amitriptyline.

Stephen who takes 10-15mg of sumatriptan. Thanks for posting this info. I tried this is the past with 25mg as it seemed logical, but it didn’t work for me. My doctor was more than happy to comply. So glad that it works for you and that others might try it and benefit. Thank you.

In the study you are referring to, rats were given a massive dose of sumatriptan. A proportional amount of sumatriptan given to a human would also likely produce some brain changes.

Dr Mauskop.. What’s your expert opinion on works like these (I know your clinical experience says different. Also appreciate your recent book)-

Triptans disrupt brain networks and promote stress-induced CSD-like responses in cortical and subcortical areas
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4760506/#__ffn_sectitle

Yes, ginger, 500 mg capsules once a day can help. It’s mentioned in my new book, The End of Migraines: 150 Ways to Stop Your Pain.

Dr Mauskop.. Is it worth taking Ginger capsules along with B2, coq10 and magnesium while on Triptan?

Yes, 5-HTP supplements can be taken with triptans. However, there is no evidence that they help migraines, let alone come close to replacing triptans.

Dr Mauskop .. Can 5-HTP supplements do what Triptan can i.e. help with migraine. Can they be taken while using Triptan?

Unfortunately, there is no evidence that CBD oil helps migraines. I do have many patients using high concentration CBD cream topically. They apply it to the forehead, temples, neck, and shoulders with good relief.

Dr Mauskop .. do you have any opinion on cbd oil, for migraines?

I have been taking Imitrex for over 20 years. I started with 200 mg in 24 hrs when my migraines were very severe. Through the years I have been able to reduce my usage to 50 mg but almost every day. My Doctor tries to discourage use but I know that I have a better quality of life with the medication. The pain of the attacks is much reduced. But I feel very guilty about taking it at all. It is like I should be able to pick the days that I can get relief and make due to the rest of the time. We need to rely on research studies about the long-term effects of Imitrex in order to the stigma that comes along with taking this medication. I am happy that I have found this group to share my experience with. I found Stephen’s comments interesting about splitting the 100 mg tab.

Just a comment – I find that 10mg-15mg of Sumatriptan (100mg broken into 8ths) taken at the first hint of a migraine is nearly always effective for me. I do this pretty much every day and have been using Imitrex (starting with injections) for nearly 30 years. I have been made to feel guilty for using so often and my doctor (a pain specialist at Oregon’s research hospital OHSU of all places) occasionally tries to limit the number of tablets per month to try to get me to stop doing this, but I have a life with places to be and things to do and would rather not spend all my spare time vomiting on the bathroom floor. I’m so glad to have found your blog. It’s nice not to feel like some back-alley drug user, getting away with something I shouldn’t. Thank you.

I find that for most people the highest dose is more effective. If someone tries a lower dose and it does not work, they often assume that the drug is not effective for them. Doctors are hard to reach at times and some require a visit to issue a new prescription, so people give up. There is not a significant difference in side effects between the lower and the higher dose. This is another reason to start with the higher, potentially more effective dose. A few of my patients who always require a second dose of the highest dose triptan two hours after the first, try taking two tablets at once. This dose which is double of the officially approved one works much better. This is particularly true for generic versions of the drug, possibly because less of the active drug gets absorbed. The total amount of medicine in the generic could be the same as in the brand, but the absorption of the drug could be less because of the way the medicine is compounded.

Dr Mauskop , What is the reason. If any, for starting dose of Triptan is the highest amount available? For example for Sumatriptan 100 mg and Eletriptan 40mg (I believe). Shouldn’t it be that patient should take the lowest dose and see if that does the job, as often said about painkillers?

Yes, there is evidence that taking 81 mg of aspirin can improve migraines. However, I’ve rarely encountered a patient whose migraines were dramatically improved by aspirin alone. Aspirin also prevents cancer but it carries the risk of stomach ulcers and bleeding. If triptans and aspirin are equally effective, aspirin is not causing heartburn, and there is no history of stomach or bleeding problems, aspirin could be a better choice. Also, in older people with risk factors for heart disease, aspirin is a clear winner.

Are there any benefits to taking baby aspirin (81mg) daily, towards migraines. Is that a treatment option? Is it better or worse than daily Triptan assuming low dose aspirin helps as a preventative?

Yes, if someone is taking triptans daily and they are deficient in magnesium, taking a supplement can help. B2, is in general less effective than magnesium and CoQ10.

Dr Mauskop .. In your experience taking supplements B2, Magnesium serves a purpose (reduction in number of migraines) if you are taking almost daily Triptan for migraines?

I cannot give individual advice without first seeing a person. However, I do prescribe daily sumatriptan, 100 mg to patients in their 70s and 80s, as long as they have a healthy heart and blood vessels.

Dr. Mauskop, should I be concerned about taking 25-50 mg of sumatriptan most days for chronic migraine headache? I’m in my early 70s. My doctor has just prescribed propranolol to try and I am worried about the possible side effects. Is it likely to prevent the headaches in order to cut down my triptan use?

Relpax usually does not reduce the frequency of migraines, it only stops individual attacks. 40 mg is what I prescribe to almost all of my patients. A few European countries have 80 mg tablets.

Dr Maushkop.. In your experience Relpax 20mg or 40 mg is better in terms of reducing frequency of migraine.

There is no way to know. This is all very individual, determined by trial and error.

I take sumatriptan frequently because I have failed many prophylactic treatments, including Botox.
I have always taken 100 mg with success. Since my frequency of sumatriptan has increased, I wanted to see if 50 mg would be adequate. If I take 50 mg at the onset, and get no relief by the 2 hour mark and take the other 50 mg, will the second dose “catch up” to the first to work together? I’m trying to understand the mechanism. I’m concerned that taking the 100 mg dose divided would not work the same way and I would have to wait 12 hours with a migraine until I could take another dose. I hope that makes sense. Thank you

If they are equally effective, triptan is probably safer. Unless you have risk factors for coronary artery disease or uncontrolled hypertension.

What are your views on Advil Sudafed daily vs Triptan daily?

I cannot give individual advice so please ask your pediatrician. In general, triptans are safe and FDA-approved for kids.

Hi doctor,I wanted to know if its OK for a 15yr old to take sumatriptan 50mg once daily for 6 days at a stretch

Triptans can increase pressure very slightly. This is not a problem in people with normal pressure. Triptans, however, are contraindicated in people with uncontrolled hypertension. So if the systolic (first number) pressure is 160 or higher, do not take a triptan.

Does Triptan known increase blood pressue and heart rate?

You can find answers to your questions by searching “Botox” on this blog. If you’d like, you can call the front desk to schedule an appointment for a virtual consultation.

I had been taking triptans for over 20 years up to 20 times per month. They have been a miracle for me. I wanted to warn people who take them more than 8 times per month. They will change the serotonin mechanisms in your brain if you take them to often. I stopped them suddenly after reaching menopause not realizing that my brain had become dependent upon the serotonin release of the triptans. My headaches ceased to nearly zero migraines per month so I did not reach for them anymore. After about 1 month off, I started to experience all the symptoms of “Discontinuation Syndrome”. I visited the neurologist and he ran every test he could think of, MRI with contrast, CT scan, EEG, Nerve test, 16 different blood tests. All normal. Discontinuation syndrome is what happens to people who stop taking SSRI’s suddenly. If your headaches stop and you have been taking them daily, you may want to discuss weaning off the triptans very slowly. I wish I would have known that they affect serotonin levels a lot like antidepressants do.

Hi Dr. Mauskop, I will be getting my first Botox Injection in next couple of weeks (for reference, as mentioned in my previous question I have failed Aimovig, topomax, Amitriptilyn, my migraines occur daily). In your experience what is the success/failure rate is with Botox, what is the safety record, is there any evidence for headaches improving and a path to eventually getting off Botox? Thanks a lot!

Ergots are rarely used now because, for the vast majority of people, triptans are much safer and more effective. This is why the few remaining manufacturers of ergots do price them “obscenely”. Oral triptans, however, are very reasonably priced.

The absurdity is that reasonably priced ergots are removed, and we are expected to take out a second mortgage for obscenely-priced triptans. I need to take Cafergot daily to prevent raging attacks which build up during the day – Cafergot is 90% effective in this, and it’s thanks to online suppliers that I can obtain Cafergot. Imingran nasal spray is prescribed by my doctor for that 10% that gets through, but only 6 sprays per script. And without a daily supply of Cafergot I’d be crippled up.

The usual recommended dose is 100 mg of CoQ10, 400 mg of B2 (riboflavin), and 400 mg of magnesium glycinate.

Dr Mauskop, what dosage of supplements CoQ10, B2 and Magnesium would you recommend Daily to prevent migraines.

Not one mention of psychoactive substances. I’m looking into it to put an end to my headaches hopefully.

Yes, 50 mg may be sufficient. I do recommend trying preventive treatments before resorting to taking a triptan every day. Ask you doctor about trying magnesium, COQ10, other supplements, Botox injections, and preventive drugs.

My use of sumatriptan has increased over the past four months to 18-27 pills per month from 10-14 pills per month. Nothing else has changed so I’m not sure if this is temporary or a “new normal.” When taking this many per month, do you still recommend taking the prescribed dose of 100 mg, or since the frequency has increased, reducing the dose to 50 mg? I see that you mentioned the pills can be cut in half. Thank you.

If sumatriptan is working, ask your doctor to read this blog post and to prescribe more of sumatriptan.

hi doctor.I hope you read this. I’m writing for you from Iran. I suffer from migraine and severe depression. it’s about 2 years that I cannot control my headaches anymore.. I suffer fromthis pain since I was 7. but now it’s worse than ever. It starts in sleep. I wake up with pain, The only way for me is to use sumatriptan , sometime I take 600 milligram in 24 hours. I really want to kill myself cause I can’t stand this pain anymore.no medication would help me here..please help me . ..what should I do????

It depends on many factors which you may want to discuss with your doctor – the dose of each drug, your age, other medical conditions you may have, side effects that you possibly have from amitriptyline, and other.

I have now 2 options to kill my vestibular migraine: 1) taking daily triptans 2) taking daily amitriptyline. Dr. Mauskop, which do you think is better choice? or which one has fewer side effects.

There is no problem at all in breaking the tablet of sumatriptan and there is no good reason for the directions to say not to.

Hello, it’s says on the package of imitrex 100mg to never break or crush the tablets. Sometimes I wonder if taking 50mg would work just as well but I’m afraid to break the tablet in half. I saw other commenters say they have broken theirs in half and now I’m wondering if it’s possible to do that? And if so why do the directions firmly state not to? Thank you in advance for your time!!

Yes, more triptans or NSAIDs such as naproxen or ibuprofen and the new oral CGRP drugs, rimegepant (Nurtec) and ubrogepant (Ubrelvy)

Interesting discussion! For people who take a triptan daily for prevention, what acute medication(s) do you recommend for breakthrough migraines? More triptans? Or a different class of medication?

Yes, some people need to take a triptan twice a day, which is not surprising considering that the duration of their effect of most triptans is fairly short.

I love this blog post, and all the ongoing dialog in the comments! I take 100 mg sumatriptan but my migraine always returns after about 22 hours. Does this mean a daily triptan won’t work for me as a preventative or do you sometimes recommend twice a day to your patients?

Yes, I have seen patients improve after stopping their daily triptan. In a small number of patients taking triptans daily can worsen their migraines and they can improve just from stopping them. I always try to stop triptans if they are not providing very good relief and are not allowing a patient to function normally. However, stopping a daily triptan that works very well and without side effects makes no sense. Some of the preventive drugs that patients are then placed on (Depakote, Topamax, Elavil, etc), are more dangerous that a daily triptan.

Dr Mauskop: I have recently come across several instances of headache specialists insisting on how the frequent use of triptans causes rebound migraines or MOH. I know you have mentioned that there’s no clinical evidence of this, which makes me wonder, are they basing this on anecdotal evidence? Some claim they see their patients improve when they stop taking triptans so often. Is there any merit to this? Have you personally seen your patients improve after reducing triptans? Thank you so much for all you do.

Triptans are most likely very safe with COVID. They are probably safer than NSAIDs like ibuprofen or naproxen. NSAIDs are now not thought to be dangerous in COVID patients but they cause stomach problems which triptans do not.

Given the contraindications for heart patients and the fact that COVID-19 is no longer considered merely a lung disease, do you have any concerns using triptans when someone has symptoms of COVID-19? Like many migraine sufferers, when I get a cold/flu, I often get migraines and I’m wondering what my safest options are for abortive relief if I come down with COVID-19.

Since we do not have long-term (beyond 3 years) experience with Aimovig and we do know that triptans are very safe, my personal preference would be to go with eletriptan. Especially because Aimovig is not working well and if you’ve tried Botox.

I am having pretty much daily migraines. Eletriptan has been amazingly effective in taking care of them. My neurologist put me on Aimovig for past 5 months. After first month of dramatic frequency decrease in migraine, it has not worked well. What would be your suggestion? To continue with Aimovig or just move to almost daily Eletriptan. My insurance doesn’t cover Aimovig currently. Thanks!

During the course of radiation, patients are often given steroids, which can help stop migraines.

Here is a potential mystery for you. Since I was in my mid-thirties I suffered from frequent headaches – anywhere from 1 to 4 a week. Then, in my 50’s, I underwent 6 1/2 weeks of radiation treatment for a tumor in my throat. Strangely, I did not suffer a single headache the entire time I was undergoing treatment. Then, after my regimen of radiation ended, the headaches returned, and now occur almost daily. I can manage them with triptans, so it’s not a problem. But can you think of why my headaches might have disappeared during treatment? Thank you, Mark

I would ask your doctor about Botox injections for prevention and naratriptan, eletriptan and rizatriptan for acute therapy.

I have no history of migraines until I had a craniotomy a year ago for a benign meningioma. Since the surgery I have debilitating daily migraines. My neurosurgeon first put me a gabapentin which did not help. He the referred me to a neurologist that tried nortryptaline which also failed. I’ve done sumatriptan but had side effects. I have also tried verapamil but had low blood pressure drops as a side effect. We have done two occipital nerve blocks with no relief. I have also been given Nurtec as an abortive that didn’t help. I have bad rebound headaches from overuse of alternating Tylenol and IBU. I know I should stop, but it is the only way I can sleep and get through my work day. Last week I did my first two emgality injections. I am becoming desperate to find any kind of relief but nothing is working and I feel like the doctors don’t know what to do for me.

I don’t know anyone in Wisconsin, but would be happy to see you once in person, after which follow-up consultations can be by telephone. Lasmiditan (Reyvow) will be available in January, but like all new drugs will be expensive, so it is unlikely you will be able to get your insurance to pay for more than 6-9 tablets a month, if any.

Dear Dr. Mauskop,

I have been on daily sumatriptan for 4 years and after 30 years of suffering with chronic migraines, these have been the best 4 years of my life! Out of the blue. my regular physician decided I should see a headache specialist and now neither of them will prescribe more than 6 pills a month. I am waiting for Reyvow to become available, but in the mean time, I have completely lost my quality of life. I live in Milwaukee Wisconsin. Do you know of any medical professionals in Wisconsin that could help me? Do you take appointments through Skype if I can have my medical records sent to you? I have tried the whole range of preventatives, but they all ended with horrible side effects and very little help. Aimovig did well for 4 months and then stopped working.

Thank you for this article AND for your continued comments and sharing of recent studies on the use of triptans for daily use during headache cycles. I’m in one now. For the last month have been having daily headaches AND split my 2.5 Naratriptin into 2 daily doses….am/pm. And it has worked well. It is wonderful to hear a headache specialist confirm what I’ve believed for years. “No one cares about your Migraiines except you”…my headache mantra for care and consults. For those of us who’ve had migraines and not had access to triptans (mine began before there was even Sumatriptin) the idea of suffering through them is worse than any possible consequence of a daily dose of a triptan that we KNOW works and for years has had no adverse effects. It’s just so good to have read this article. So grateful.

All of the information regarding medication overuse headaches was collected in surveys and not surprisingly those with frequent migraines tended to take more triptans and their headaches worsened and they ended up taking even more triptans. This is so called correlational study, but correlation does not mean causation – it is more likely the reason people were taking more medicine is because their headache worsened rather than because they were taking medications. See this post for a link to a good article by leading headache experts dispelling the myth of MOH – http://www.nyheadache.com/blog/medication-overuse-rebound-headache-is-a-myth/.

Dear Dr Mauskop, I stumbled upon this article some time ago and I found it to be very interesting. I was wondering if you could elaborate briefly on the “no evidence” part. What makes the current studies on MOH by triptans insufficient or incorrect? Would it be possible to cite some of these articles? (I apologize if by any chance this topic is already covered in this post — I have looked for it throughout the thread and I haven’t found it so far). Thank you very much for your time.

Perhaps the doctor who prescribes oxycodone will be willing to do it since Imitrex is a lot safer. If not, you can come for one visit to see me in NY and I will be happy to prescribe enough sumatriptan for you. Subsequent follow-up consultations could be by phone. If you live far, try finding a neurologist who is willing to prescribe it for you.

I’ve had sever chronic migraines for the past 15 years. They basically came on from nowhere and I remember my first one because it was christmas morning and I basically blacked out the entire morning. Since then, I get them more and more often. I have tried EVERYTHING, probably 100 different medications, 20 different doctors. I had one neurologist pumping me up with more and more opiates (they worked great but I had to keep taking more and more to get the same relief. I was taking up to 300mg of oxycodone IR daily. Some neurologists told me as long as I am taking the pain meds, I will never find a solution for the migraines. I went off opiates for 2 years, but my headaches only seemed worse. Imitrex does help, but I cannot find a Dr willing to give me 60 pills a month, which is what I would require. Now I take a much less dose of oxycodone (60mg per day) and If I am lucky I can get 25-30 imitrex. I am in pain daily, and it gets to the point where I cant take it anymore. Quality of life must be better than this! Any suggestions?

It’s very unlikely, but you may consider treatment with Botox, nortriptyline, as well as exercise, meditation, magnesium, and other supplements.

This is interesting for me because I have had chronic daily headaches for 1.5 years now and before this pain started, I was having nearly daily migraine pain (not full on migraines with light sensitivity, just pain on one side of my head). I thought that my overuse of sumatriptan ultimately caused my now chronic tension headaches (I don’t get migraines very often anymore). But this article seems to suggest that this couldn’t have been the cause. Still, I wonder whether some damage was done to cause my daily tension headaches that I have now.

Those are complicated questions that you may want to work on with your neurologist.

I started with migraines nine years ago. I have seen several neurologists but none seem to take migraines very seriously and some of the daily preventatives that they are telling me about sound like they have a ton of side effects. Until now, I would get about 4-8 per month. However, the last month or two they’re almost daily. I’m currently taking sumatriptan and have stopped excedrin migraine after reading your blog. Part of me wonders if I am just in a series of rebound headaches at the moment, I can’t go without some kind of relief as I have two small children I need to function. I am going for an MRI with contrast this week. The questions I have are: for the new preventatives that are out there really worth the side effects? Are there any that you would recommend as being more effective? What is the daily preventative with the least amount of side effects? Sumatriptan makes me extremely groggy and depressed and I just don’t feel like myself. My neck is constantly stiff.

Thanks for your quick response! Taking oral triptans on an empty or full stomach may explain the variability I’ve had with their efficacy. For people who require daily triptans, what is your general recommendation? 50 mg of oral sumatriptan at bedime plus injectable sumatriptan for break-through migraines? I’d appreciate any information. My doctor is open to the idea but doesn’t have any experience with daily triptans so I’d like to share specific information with her. I’ve tried about six preventatives, including Botox, with no effect on my chronic migraines. Thank you!

Triptans work faster, which makes them more effective if taken on an empty stomach. Nasal spray can be faster than any pill, but it can also be inconsistently effective. This could be due to nasal congestion or other factors. Zolmitriptan nasal spray (Zomig NS) tends to be better than sumatriptan (Imitrex NS). Injections of sumatriptan are the most effective and the fastest acting.

Are triptans more effective when taken on an empty stomach or with food? Are nasal and/or injectable triptans more effective overall or do they just provide faster relief? Thank you!

I would show your doctor this blog post with some of the comments as well as an abstract of the article by three doctors, one of whom, Dr. Elizabeth Loder is the former president of the American Headache Society. Its title – Medication overuse headache. An entrenched idea in need of scrutiny.

I’m sorry if this is a repetitive question. I have been having migraines for about 4 years now. Sumatriptan 100mg tablet works very good for me. Most days 1 tablet a day. My PC doctor has sent me to specialists, MRIs, ultra sounds, special blood test,etc all came back negative. My PC has prescribed me 45 (100mg) a month. Also a quarterly meeting with her to discuss my symptoms, diet and exercise. Recently, about the last 3 months, the pharmacist refuses to fill my prescribed amount. Saying they are bad for you and not intended for daily use. He recommended Topamax, a medication made for seizures and some antidepressants. I have tried both. The side effects of these are horrible. Not to mention I do not have the symptoms that these medications are made for.
After the pharmacist called my PC with his input she is now hesitant to prescribe 45 a month. Even if she does the pharmacist won’t fill.
I am so frustrated. Sumatriptan is an affordable and successful way to manage my migraines. I do not want to spend more money on specialists and tests that continue to be negative. Sumatriptan is not a narcotic. Why is the pharmacist making such a big deal of this? What argument would you recommend me to present to them both?
Thank you in advance for your input!
Nancy

MIgraines, IBS, depression, and other condition involve serotonin, but it is not too much or too little, but rather having the right amounts in the right places. Triptans and Zofran do not work in the opposite ways, they work on very different serotonin receptors and we often prescribe them together.

I have migraines and IBS. I have been unable to determine if both of my issues are caused by too much serotonin or not enough. Is it a bad idea to take a triptan (sumatriptan) with zofran, because they work in opposite ways? I was unable to find any contraindications.
Thanks again, you have been extremely helpful.

Surprisingly, short-acting triptans can be as effective for the prevention of migraines as longer acting ones.

So doctor is it better to use a triptan with a longer half life, Amerge (naratriptan), Frova (frovatriptan) if you are using it as prophylaxis for a migraine? If so do you have a preference? Additionally would you recommend having a short acting triptan for any break-through migraines?
Thank you

No, there is no evidence that prolonged use of eletriptan (Relpax) or any other triptan causes any negative effects on the heart or other organs. However, as people get older, they often develop high blood pressure, diabetes, high cholesterol, and other risk factors for heart disease (smoking is another strong risk factor) and if those are present, heart testing is indicated. A stress test or a coronary calcium scan are two tests that a doctor may order. Triptans should not be taken by people who have coronary artery disease, but triptans do not cause it.

I have taken triptans almost daily since 1992. I started with sumatriptan as injections, as soon as it was available I took sumatriptan as tablets. Then I tried to use naratriptan because of it’s longer half-value period, I thought I would be able to take fewer tablets a day because of that. When Relpax/eletriptan was launched I changed to that and was happy to find that I no longer got the side effect of feeling a mild pressure on my chest.

I think I started with Relpax in 2000, so I have used that for almost 20 years. Initially I took 40 my tablets up to three times a day. I started to use Cefaly in 2014 and it decreased my daily intake of Relpax to 20 mg once or twice a day, most often just one. Some days I take none. I also started to use amitriptyline in 2017.

I experience no side effects from Relpax. I wonder about any possible hidden side effects, like how my intake of triptans might affect my vessels and my heart. What kind of tests would I have to go through to check that up?

Yes, sometimes half the usual dose of a triptan can be enough for the prevention of attacks.

When your patients take triptans daily do you reduce the dose from what they would take when they start to get a migraine?

OMG, I am so happy that I found your blog. If I listen to my body, it tells me the same that you do about triptans and other drugs used for migraine. I tolerate triptans very well and take them almost daily, even though I have managed to decrease the number since I reached menopause.

This blogpost reminded me to try to cut down on ASA+caffein and just take ASA for a while. I think they might give me some rebound headaches, but I doubt very much that eletriptan causes that, since I managed to cut down on eletriptan while I still take a couple of ASA+caffein every day.

The shadows from the old migraine drugs should not cast their shadows over triptans. Triptans are a lot better.

Thank you for your last response. Do you treat many people with both IBS-D and hemiplegic migraine? Most of the time these are women so being a man there is not much information on it for me. I believe that I have a serotonin issue or a central sensitivity syndrome issue and was wondering if there was a medication that might treat both the IBS and migraine. Sumatriptan has worked to stop the migraine after I get the aura and didn’t know if taking that daily might be good prophylactic treatment and help with the IBS. Thanks again

Lotronex (alosetron) is not a triptan – triptans work exclusively on 5HT1B and 5HT1D serotonin receptor subtypes, while alosetron works only on a very different, 5HT3 receptor. A nausea drug, ondansetron (Zofran) also works on 5HT3 receptor, but alosetron is not approved for nausea, only for severe IBS with diarrhea.
As far as sumatriptan, you can buy 9 tablets of sumatriptan for $15 without going through your insurance by checking for coupons and discounts on GoodRx.com. You just have to ask your doctor to send a prescription to a local pharmacy with the best price.

Have you ever used Lotronex for daily use for migraines? It is indicated for women with IBS but it is a triptan. I am a male with IBS and migraines and feel that this medication might be perfect for me but probably cant get it because of the indication. I believe that a serotonin agonist is what I need. I take Sumatriptan when I get the aura for my hemiplegic migraine but the insurance company limits how many pills I can get per month.

Yes, I have a few dozen patients (out of thousands, so it is not a common occurrence) who have been taking triptans daily for many years without any adverse effects. The new drugs, CGRP mAbs, gepants, and ditans (lasmiditan is the only member of this class that is getting close to FDA approval) are too new to know how safe they are in the long term.

Do you have patients that have been taking triptans daily for years? Are there any concerns about daily or frequent use of triptans long term?
Will ditans be considered safer for daily or frequent use?
No matter what I try, nothing works like sumatriptan for me. Aimovig has helped a little but sumatriptan is the only thing that allows me to function and have more of a normal life.

For some of my patients who wake up every night or morning with a headache, I recommend take sumatriptan or another triptan preventatively before bed time. Ask your doctor about doing that. Triptans are much less likely to cause rebound than Excedrin or Fioricet because they contain caffeine.

My headaches have been daily for over three years. Topamax had terrible side effects, although it gave me some relief. Excedrin Migraine gave me relief, but I feel it has raised my liver enzymes. My headaches occur primarily at night when I am sleeping and I get up every night and take an Imitrex. I have neck pain and read that Botox can make this worse. I have been worried that the Imitrex daily is harmful, but after reading your article I feel better. Doctors have told me that I could be having rebound headaches.

Migraines often occur on one side and it is not unusual for them to switch from side to side. So, there is no need to search for a different diagnosis. I always recommend trying various treatments to avoid taking sumatriptan not because it is dangerous, but because headaches are usually still disruptive of normal life. Magnesium, exercise, meditation, Botox and many other treatments can help.

Hi Doctor Mauskop, The migraine that I suffer from is completely due to certain food and drink: citrus fruits, all dairy products, fats, alcohol, fumes, any food containing chemicals e.g. eggs, fish, meat, food in packets with conservants… liver and thyroid tests always come out perfect so for the last 37 years I haven’t been able to find out why these headaches occur. I only know that without Sumatriptan I couldn’t function, migraines so frequent that sometimes they are almost daily. It is so difficult to know what to eat and to keep such a strict diet as one day a certain food won’t produce migraine yet another day it will. Thank you so much for your views on this drug which I was a bit scared of taking so often yet it is the only thing that brings relief. One day the migraine is on one side of the head and the next time it occurs on the other side. What could this mean? I am at a loss toknow and have visited just about every sort of doctor in existence yet not one has been able to diagnose it. I would be grateful forever for any views or light you can give on the subject.

The CGRP drugs are being developed for both prevention and acute treatment of migraines and there is no scientific reason why triptans cannot be used for prevention as well.

Thank you Dr Mauskop. I wish they could come up with a preventive medication that was as effective as triptans. Even the CGRP antagonists don’t seem to help as much as triptans do.
I take sumatriptan an average of 12-15 times a month and without it, I wouldn’t be able to function. I know it doesn’t cause MOH for me, because I sometimes have been able to go without it for 7-11 days. Anytime I tried to delay taking it, it only makes the migraine worse and won’t stop until I take it.
I wish more doctors would stop recomending the limited use of triptans, which only seems to make things more challenging for patients.
I also hope to see you as one of the headache experts at the Migraine Summit one day to help educate others about it. Thank you truly for all the useful information.

This post from 2012 is my most popular one with 269 comments so far and it is the one that comes up on search engines when people look for information on daily use of triptans. You may also want to read a related post from 2017 which describes an article by three leading headache experts on this topic. The article Medication overuse headache. An entrenched idea in need of scrutiny was published in a leading neurology journal by Dr. Elizabeth Loder, former president of the American Headache Society who is currently at Harvard, her Harvard colleague, Dr. Paul Rizzoli, and Dr. Anne Scher, one of the top epidemiologists in the migraine field.

The first drug in the family of ditans, lasmitidan should become available within a year or so. It will probably be as effective as the triptans, but will not have contraindications in patients with heart disease and other vascular problems. These contraindications applies to a relatively small proportion of migraine sufferers because most of them are young healthy individuals. Migraine is most common in the 20s, 30’s and 40s with three times as many women affected as men.

Dr Mauskop,
Do you have any idea when ditans might be available? Do you think they will be as effective as triptans? Thank you

You may want to try other triptans which are cheaper and may work as well as eletriptan (Relpax). Naratriptan (Amerge) costs $2 a pill at a mail order pharmacy HealthWarehouse.com, while rizatriptan is about $1.30 a pill.

Dr. my problem is the cost of Relpax. Very expensive. At $13 a pill and as often as I have to take it I am broke all the time. If it wasn’t because my husband helps me financially I wouldn’t be able to afford it. Relpax is the only med that takes my pain away. Is there anything else that will work just like the relpax and take my pain away completely that I can afford?? I have tried sumatriptan and it did not work for me. The preventatives also don’t do anything for me. Thank you.

Although this is uncommon, some people do develop rebound (medication overuse) headaches from triptans. Rebound headaches are progressive to a point where headache becomes daily and does not respond to the triptan. The only treatment is to stop the triptan and typically improvement occurs within a week. Actually, according to a study by Katsarava and his colleagues in Essen, Germany it took only 4 days for patients overusing triptans to improve, which was a shorter time than for pain medications. However, if headache persists beyond a week, this means that it is not a triptan-overuse headache. If that is the case, taking a triptan daily or twice a day may actually be a good long-term preventive strategy. Please talk to your doctor about this since migraine sufferers with coronary artery and other vascular disorders or multiple risk factors for vascular disease should not take triptans.

Triptans definitely cause rebound migraines for me. If I take it more than three times a week for more than a week or two, I develop a pattern of migraines every 22-24 hours (relieved by taking another sumatriptan). My question for you is whether you have any experience with patients successfully using daily triptans despite that fact that they are in fact getting rebound migraines from it? Or are rebound migraines a progressive condition that will continue to worsen (requiring more medication, or the medication becoming ineffective)? I’ve tried Botox, Aimovig (which made my migraines significantly worse), gabapentin, propanolol and nortriptyline. Thank you!

i suffer from headaches periodically for years …currently having daily headaches which usually last about 45 minutes to 90 minutes after taking 40mg of relpax its been about 6 weeks this time after going about 5 years relatively headache free…back then had headaches every 48 hrs for longer than i can remember was diagnosed as cluster headaches have O2 which helps at times…my headache always starts with a plugged left ear then spreads into my temple then behind eye and sometimes when especially severe into cheek and roof of mouth…hoping like hell that they just go away like before …oh i also take propranolol twice a day but highly doubt if it does any good…since the headaches are daily now been taking relpax each time

I can’t give individual advice without seeing you first, but we do have a good number of patients who had been taking triptans daily and whose migraines dramatically improved with Aimovig.

Wow, I just read this and I am more confused than ever. I have had migraines for over 30 years (I am 51yo), have tried many, many anti-depressants, anti-seizure, beta/calcium channel blockers, NSAIDs, pain meds, and Botox after first approved by FDA. None of those worked long enough to stay on them, and often the side effects were worse than having the migraine. Currently my medicines are Relpax/Zomig (I get 18 Relpax a month and 6 Zomig Nasal Spray), I switch between the two, Percocet and Soma. 3rd ER visit (over 30 years) for intractable migraine was 10/11, they gave me an IV drip of Benedryl, Reglan, and eventually Fentanyl and then Dilaudid. I left with a pain scale of about a 5, and later had to take ANOTHER Relpax at home. Have gotten to the point where I am having a migraine literally every 24 hours, and most days I wake up with it. Recently saw a new Neuro as my last Dr. had a car accident and can no longer practice medicine. New Dr. HATES Soma (prescribed Tizanidine instead), and also does not like the fact that I take a triptan every day. Told me that if I stopped the Soma without tapering I would be at risk for having a seizure. She wanted me to stop the Relpax/Zomig cold-turkey for 3 months, but realizes that can’t happen, so she prescribed Nabumetone, and said she would be fine with me taking Nabumetone 3x per week and a triptan 3x per week, in the hopes of breaking the MOH cycle she says I am in. NSAIDs have never worked for me and I am afraid I will fail. She also prescribed Aimovig; I am set to take my first injection tonight, but maybe I will wait to see what you say. I am starting to be fearful of never getting out of this cycle and I don’t know what to do. I feel as though a lot of doctors blame the patient for getting into a MOH cycle, but honestly, what person would want this? I have to work and take care of my family and I am flat out scared.

We’ve setup our own patient driven research. We collect data about our attacks (in real time) and all the treatments we do. We hope to find trends of best treatments.

To refer to the sumatriptan: I personally use a lot of it and once I stopped them I never got the same intensity of attacks anymore. It always broke off an attack, while I was alway in the region of 8-10 in intensity

After stopping, didn’t record almost any of 8-10, mainly 5-7. Same rithem of attacks though.

We hope to use our data to find the effectiveness of sumatriptan with our own data.

If you wife has an excellent control of her migraines with no side effects from a steady dose sumatriptan that suggests no rebound. However, if her headaches are still disabling in any way or she needs to keep increasing the dose, or she has side effects from sumatriptan, then she needs to get off it. Botox can be very helpful in getting off triptans and other abortive drugs and if it is not effective, one of the new CGRP monoclonal antibodies (erenumab, or Aimovig, fremanezumab, or Ajovy, or galcanezumab – Emgality) may provide good relief. All three companies making these monoclonal antibodies offer a free trial.

Dr. Mauskop, you write “Rebound, or medication overuse headaches do happen with triptans, but are very rare when treating both migraine and cluster headaches. My estimate is that less than 1% of patients develop it.”
Do you have any indicators you look for that suggest that MOH may be occurring when you see a patient that takes daily triptan? My wife takes sumatriptan almost daily and we’re often wondering how concerned to be about MOH but stopping it “just to see” is hell.

I would recommend going to Johns Hopkins in Baltimore – they have a team of neurosurgeons specializing in trigeminal neuralgia.

Rebound, or medication overuse headaches do happen with triptans, but are very rare when treating both migraine and cluster headaches. My estimate is that less than 1% of patients develop it. Since I see exclusively headache patients, I have seen patients who have gone up to taking a triptan up to 10 times a day. In these rare cases the triptan can be stopped with the help of DHE infusions, a course of steroids, occipital nerve blocks or prophylactic medications.
As far as the safety, if the patient is older and has risk factors for coronary artery disease (smoking, high cholesterol, diabetes, hypertension, etc) we refer him (it is more often him than her with cluster headaches) to a cardiologist for clearance.

I have chronic cluster headache and my daily treatment is 360mg – 480mg Verapamil and 2x 40mg eletriptan (Relpax). I take Relpax now since 6 weeks an it helps a lot. So far i have no side effects. I live in europe (sorry for my poor englisch) and a common opinion here is that daily treatment with triptans ends up in a rebound. By reading this blog i learned that daily triptans are quite safe. From your point of view and your experience how high is the risk for a rebound with a daily dose of 2x 40mg eletriptan each day as a long term treatment.

Thank you so much. I really appreciate your time, and this blog. This has been a lifeline.

Every person responds differently to each triptan, so there is no best or worst. I would call Dr. Judith Lane at BLue Sky Neurology and ask her if she’d be willing to prescribe a triptan for daily use. So far, after 25 years on the market, triptans have not been found to cause long-term side effects or complications.

I’ve done the botox, depakote, and Countless other preventatives. I’m 57 and have been fighting this since I was 18. I am otherwise healthy, good weight, etc.
I’m currently a surreptitious daily triptan user – as my Doctor is putting her foot down at about 18 a month. I am using a stock pile from previous days of testing myself for MOH – going off triptans for months and even years at a time. I know I only have about 9 headache days a month (3 sets of 3 day events) if I am not on triptans. But they are days of hell. Completely incapacitating, I could never hold a job being so unreliable – plus – I eventually even found myself considering suicide. So back on triptans. So – now I technically have 30 headache days a month – but I don’t think of them as headache days! Why is it better to make people go off triptans because they are having “MOHs” – when that causes so much more suffering and disability? I wish the medical profession could consider each case on their own merits – weigh the pros and cons – and let the patient and doctor use their common sense in making the decision. But they pound it in to the community that anything over 10 a month is reason to take away the lifeline regardless of the consequences. Sigh.
A few questions –
I’m using frova and relpax – I tend to go on streaks of either one, rather than bounce back and forth. When things work well – I can take one frova a night prophylactically and be absolutely symptom free for up to a week – before I get a tickle earlier in the day that insists I better take something sooner.
The relpax seems to require more frequent “supplements”.
I have not tried Naratriptan or almotriptan.
Questions –
Which triptans are usually better for daily use?
Are there any clinics in Colorado that you are familiar with, that are OK with prescribing a daily dose under this kind of circumstance?
Lastly – what are the thing that daily users like myself might face in the future – in terms of complications, side effects, or eventual medication failure?
Thank you so much for sharing your time and expertise!

Thanks so much for your prompt reply, your suggestions and your kind offer. I’ll follow through
and let you know how it works out.

You may want to ask your doctor to check out this blog post and tell her that I am happy to speak to her. Another option is to find a doctor who is willing to prescribe enough Amerge. Perhaps your cardiologist who performs the stress test would be willing to prescribe.

I’m almost 80 and have suffered from migaines on and off since I was a teenager. My triggers are barometric pressure and stress. Like others on this forum, I’ve tried every therapy, preventative and medication, including botox, over the years and the ONLY thing that works for me are triptans. In the past few years my migraines have become chronic and Amerge has been my lifesaver. My family doctor retired this year and the new young doctor who took over her practice will not prescribe Amerge for me, citing my age and risk of stroke. This despite the fact I have annual stress tests and my heart is in great shape. I am also otherwise very healthy and active. The last thing I want is to spend the rest of my senior years lying, nauseous, in a dark room. The doctor wants me to handle these vicious headaches with Tylenol, which is like trying to kill sn elephant with a fly swatter. Do you have any other suggestions?

It sounds like you have cluster headaches (oxygen is used only for clusters) and cluster patients often need to inject sumatriptan twice a day until the preventive treatment kicks in or they get an occipital nerve block. As long as you don’t have coronary artery disease or multiple risk factors for it (smoking, cholesterol, hypertension, diabetes, family history, etc) it is safe to do that.

What are your thoughts on daily use of SUMAtriptan injections, twice a day? While I await to get a referral for Oxygen I have been using them twice a day for about a week now. It seems there is hesitation from Dr.’s. to give more than two injections at a time, no cost issues are present. Essentially, am i at risk if i use two injections a day for a sustained period? 6mg/5ml.

Thanks so much. I’ll try her steroid pack first, and then speak to her around the possibility of Botox. It looks like there are several local options for that. Thanks for the information on Sumatriptan and abdominal migraine, and thanks for running and maintaining this blog. It’s good to run into a doctor who goes above and beyond.

25 mg of sumatriptan once or twice a day is a relatively small dose, considering that the maximum FDA-approved daily dose is 200 mg. However, prevention with Botox injections would be the most effective and the safest option. You can find a local neurologist who gives Botox for chronic migraines here.

As far as abdominal pain, very rarely it can respond to sumatriptan, suggesting a migraine mechanism. On the other hand, equally rare is abdominal pain caused by sumatriptan, which can lead to a serious complication of bowel ischemia. Endometriosis, is a much more common cause of such pains.

Do you have any recommendations for when migraines are only part of the picture? I have MS, and while I have had intermittent, infrequent migraines for years, they have recently become a major problem, happening nearly every day for over two weeks. Sumatriptan (25 mg, usually once, sometimes twice a day with minimal breakthrough pain) has been a godsend, and while I’m not averse to the idea of prophylaxis, the migraines seem to be lessening in severity over time. I suspect they’re part of an MS exacerbation, to be honest.

Meanwhile, my neurologist (who I respect immensely around her treatment of my MS, and who generally favors a cautious approach) seems very nervous about MOH. I used to take Vicodin for my 1/month migraines, which tended to be severe, but short-lived. I tried topamax, but had a very unpleasant reaction. She’s now moving towards amitriptyline and/or a short course of high dose steroids (which makes sense). Meanwhile however, I am having a hard time advocating for myself around keeping access to a drug that works wonders with no side effect profile to speak of, and when you’re on as many medications as I am currently on, that’s a big deal.

I’ve been referred to the local headache clinic, but there’s a three month wait, and they demand that all patients be off all opioid medications for six months before being seen. I don’t take the ones I have often, albeit more lately since I have some currently undiagnosed abdominal pain that is intermittent, but Intense. I hesitate to make a promise I can’t keep, especially since I may require a diagnostic laparoscopy (endometriosis is on the table). I am frustrated by the lack of coordination of care, and the seemingly glacially slow progress towards a solution.

How do I navigate the maze of MOH paranoia and liability aversion and communicate that I need access to prophylaxis, acute treatment, And pain medication (pending diagnosis and treatment)? And is there a possible connection between my mystery low-abdominal pain and the migraines? They seem to inversely correlate. Clearly I'm going to have to research these connections myself, given the increasingly siloed and specific expertise of my doctors and their apparent inability to communicate with one another. I understand the systemic limitations, and don’t blame them. I just need to hold down a job and complete grad school while I do a lot of running from one to the others like the world’s slowest game of Telephone. Any advice?

I would suggest seeing a headache specialist who will need to find out many other details of your condition before giving you some advice.

Hi Dr. Mauskop, over the last year i’ve been having trouble finding out why my “migraines” started happening , they start after exercising and i notice that if i dont exercise and take half of my triptan dose every other day it works as a preventative, im pretty sure the blood vessels in my head are dilating even when not exercising and when the medicine wares off its and odd feeling if i breath in deep my face flushes my head has a sort of radiating pain , ct scans were normal, i only get full blown migraines rarely but i get some symptoms daily pllease tell me what you think

I would suggest trying taking magnesium and CoQ10 supplements (see my posts on those) and Botox injections.

I have suffered migraines for 40 years (I’m 57) for many years only once or twice a month. In the 90’s I tried Triptans which almost always work – no other treatment has ever worked for me. After about 5 years of this my migraines got more and more frequent and now I take triptans up to about 15 days a month. The migraines come usually in bouts of a few days up to a week with short periods without. I’m worried they are rebound headaches as they return after about 24 hours – If I am sick with a cold or the flu they return every 6 hours. I’ve not been able to test if they are rebound as the pain is too intense so I always end up taking a triptan after some hours of agony. I don’t think I could ever face a week or two of this.

I used to suffer from two types of migraine, one which I call ‘ordinary’ and one that always was brought on by physical excercise. The second one did not respond to triptans. Now many years later they have ‘morphed’ into one migraine that responds to triptans but I still get migraines some hours after my pulse rate is high for more than about 15 minutes. It seems this is getting worse the older I get so I fear I’ll end up getting a migraine from walking up a flight of stairs. In order to not end up in too bad shape I have to excercise and will get more migraines but if I don’t excercise at all I’ll get them from just mowing the lawn – a bit of a problem. My migraines are triggered by excercise and watching a screen (TV or computer) and just as often they come without me doing anything that triggers them. Do you have any advise?

Stopping triptans for about 10 days should be enough to see if they are causing rebound or medication overuse headaches. It takes much longer for narcotics (opiates) and butalbital (Fioricet). The usual substitutes are NSAIDs, such naproxen, ibuprofen, nabumetone. Since these are considered capable causing MOH (but I think it is as rare as with triptans), they are not supposed to be taken more than twice a week.

Thanks for this informative blog! I’ve had chronic daily headaches and frequent migraines for the past 13 years. However, since January, my migraines have gone from 2-3 per week to every day. Before making my peace with daily triptans, I’d like to see if they are MOH. I have two questions. 1. How long does someone need to avoid triptans before they know it’s chronic migraine, and not MOH? 2. Are there any substitute medications that one can take during this testing period or will I need to go completely medication-free for the duration? Advil? Any restrictions on dosage/frequency? Thank you!

Regarding my post : ” Tippi says: 06/09/2017 7:12 pm” – do you think the increase and change could be due to my sons age, testosterone levels/puberty? TIA 🙂

Yes, this is a complicated issue. Here is one of my older posts on MTHFR, folic acid, vitamin B12, and migraine. I would encourage migraine sufferers to get genetic testing through 23andme.com not necessarily because it will help their migraines directly, but because with data from a large number of people 23andme can make important discoveries.

I have one more question that I would love your opinion on…I have a support group on FB for parents with children/teens with Migraines. A lot of them are getting testing through 23 and me for specific gene mutations (?) that might be effecting migraines, a lot of them are testing positive for heterozygous, MTHFR gene – do you think genetic testing is benificial? Do these specific things effect migraines? It is so confusing. I know there isn’t a short answer to this but thought you might have an opinion. TIA

So my son went from having 10 to 12 bad migraines a month using triptans with complete relief to now having headaches everyday. Since October he has been using triptans daily with complete relief. I have written before on this blog, although I feel these are not rebounds, how would one know if they are? Our migraine / pain specialist believes that his migraines have escalated due to entering puberty and she is fairly confident once his testosterone levels out, so will his headaches. His daily headaches started in October at 12 years old, he turned 13 in February of this year. I don’t know what we would do without his triptans they have been the one thing that gives complete relief but I always have in the back of my mind are they what are causing the daily headaches but I don’t see how. He has tried several preventatives that gave very bad side effects. Also tried Botox with no relief. Praying his doctor is correct and one day life will go back to normal 🙂 Thank you for your blog, comments, recommendations and professional experience, it really helps 🙂

I would strongly advise asking your doctor about Botox injections

I would recommend asking your doctor about magnesium and CoQ10 supplements and Botox injections.

Firstly, thank you for your blog. It is very informative. I have suffered from headaches and migraines since I was three years old. I am now 65. Gradually, the migraine frequency increased and I now I get them daily. I take Sumatriptan every day at the onset of pain, and they are very effective. I did not know you could take them preventively. I have just been prescribed Mirtazapine for insomnia and anxiety, starting with half a 15mg tablet for four days. However, for the first two days I experienced a massive migraine about three hours after taking the Mirtazapine. The pain woke me up. Also, I was so heavily sedated that I have not been able to function. I have temporarily stopped taking the Mirtazapine until I can see my doctor again. Do you have any suggestions as to alternative medications that I might request that will not have such awful side effects? I should add that I am generally very sensitive to drugs, so it may be me and not the medicine. How would I take Sumatriptan preventively? I have tried preventives such as Propranolol, Sodium Valproate, Cymbalta and other SSRIs with no benefit. My thinking is that if I can get the migraines under control, my sleep and anxiety may improve. Thank you.

I have struggled with chronic migraines for the past several years. I had ECT treatments from 2010-2012 that resulted in long term memory loss. I can’t take most medications because of side effects, particularly since a lot make me suicidal, cause a great deal of stomach pain, or cause me to have to have seizures. I have particularly had a lot of sharp pains on the top of my head after hitting my head really hard about 2 years ago. For whatever reason, my neuro never ordered an MRI after this. After stopping caffeine, my migraines improved a great deal, with the exception of during PMS. I was recently on birth control to try to help with that and other PMS symptoms, but it seemed to make the migraines worse. So, I have been off for about 2 weeks now. I am now struggling with short term memory problems, forgetting how to spell simple words, etc. I have frequent seizure dreams, though not sure if I am having an actual seizure though I wake up feeling even more groggy after one than I was when I went to sleep. I had a right sided migraine yesterday that was so bad I almost had my husband take me to the ER. My right eye felt like it was going to explode, and the right side of my neck was very tight, stiff, and swollen. I took a Naratriptan tablet, but my migraine seemed to get worse for a while before it finally improved some. The head pain has improved today, but neck is still very sore and tight while also causing shoulder pain. My neuro, since he seems at a loss of what to do, seems to say things like “snowball effect” and psychological, though I am sure that is not all it is. By the way, ECT was done because of severe major depression following a miscarriage that was, in fact, worsened by the antidepressants they were giving me to start with. Since coming off of those meds, psychologically everything is much better. Any suggestions? I am only 40, but feel as though I am going into early Alhzeimers.

Cefaly does help some of my patients with migraines, but less than half of those who try. Because it is very safe, it may be worth trying. I would consider trying different medications (there are more than 20 to try), meditation, magnesium, Boswellia, and CoQ10 supplements.

I’ve suffered with migraines for the past 24 yrs (between 1 – 6 a month). 4 years ago we flew to Italy and I suffered from sinusitis which was so bad that I couldn’t bear to move and a Dr came to the hotel and prescribed antibiotics. Since then I have suffered from daily headaches, on top of the migraines. In the past I have had MRI and CAT scans and I’ve tried accupuncture, seen a chiropractor, had Indian head massages etc. I have been having Botox for the past 2 yrs but the headaches/migraines continue. The only thing that gives any relief is Sumatriptan. Is there anything else I can try or do? Do you have any feedback on the Ceflay – a headband from Belgium which gives out electric pulses? Thank you.

I’ve seen several
comments re: neck discomfort when taking a triptan. I used to experience muscle tightness in my neck and pressure in my chest for about 20-40 minutes with each pill. But years ago, I discovered that if I take a vicoden, or MAYBE just some Tylenol, or ibuprofen when my stomach could handle that; I would NOT have those VERY uncomfortable temporary side effects with triptans. My headache specialist okayed this practice.
I’m wondering if others might find this useful, and perhaps enable some more people to use triptans.

Rebound headaches from triptans are rare, but can happen, especially with cluster headaches. See other blog posts on treatment ideas. You can also enroll in a cluster headache trial of a CGRP monoclonal antibody, if you can find a local investigational site. You can google it.

Dr. Mauskop, I suffer from cluster headaches. My current cycle started a little over 3 months ago (after no CHs for a year!). I get hit 2 to 5 times per day. Unfortunately, the only thing that seems to help is Sumatriptan to help abort the headache. Insurance will only cover 12 pills per month, so I stock up on them when I am not in a cycle. I limit myself to taking 50mg twice per day (I break 100mg pill in half).My concerns are: 1) Is taking a triptan every day safe (I’m 55 and I don’t have heart disease). 2) Can the triptans cause rebounds headaches. Also, do you know of any thing new for CHs. I try to keep up with the latest through the internet, but haven’t seen any new treatments available. I can’t find a headache specialist in my area, plenty of neurologists, but quite frankly, they just don’t understand CHs. Any thoughts. I live in the Virginia Beach area. Thanks..

Yes, you should definitely see a headache specialist. If you live in the US, see below the two directories mentioned in my previous reply.

I take Sumatriptan daily. It seems to calm any other headaches that might want to come on. My headaches seems to come from maybe sugar related or not eating for a long time. Should I see a headache Doctor? If so, which kind? It seems my are related to food and what it has in it but I am at a loss for where to begin. All I know is that when I start to get a migraine I take one Sumatriptan along with 3 ibuprofen and 1 migraine Excedrin. That curtails any other headache for around 24 hours. Can you advise?

You can check these two directories for headache specialist: https://americanmigrainefoundation.org/find-a-doctortreatment/ and
http://www.headaches.org/physician-finder/

Dr. Mauskop, I very much appreciated your article. I suffer from daily headaches. My neurologist that I have been seeing for some time, has been giving me Botox injections and prescribing preventative medications without success. The only thing that takes my headaches away is sumatriptan, yet she refuses to prescribe their daily use. How do I find a doctor that if nothing else works will allow me the daily use of sumatriptan. Thank you.

It is very unlikely that there was any interaction between sumatriptan and rizatriptan since both drugs are washed out from the body within 3-4 hours. The 24 hour restriction on mixing these two drugs that is indeed listed in the FDA-approved package insert has no basis in science. The most likely cause of your symptoms is the fact that your body does not react to these drugs well.

I have recently been struggling with migraines. My doctor first tried rizatriptan and RX ibuprofen. Although I did get some relief, I was still faced with constant/daily headaches. So, my doctor decided to switch to SUMAtriptan. She did tell me not to take them together. So, I started taking it at night. However, it made me feel awful and SO sick, and I vowed to NEVER take that med again. So, the next morning, awaking to pain, I went back to the Rizatriptan. But, an hour or so in, I started to feel VERY woozy, dizzy, just out of it, sweating, blurred vision, etc. My coworkers were concerned and the nurse checked me out. My vitals were normal. I was concerned, so when I looked up the SUMAtriptan, I discovered that you are NOT supposed to take the SUMA and Rizatriptan closer than 24 hours together. I took them about 9 hours apart. While I do feel better overall, I am still feeling woozy and dizzy at times (although I am still on the Rizatriptan). Is there anything I should be concerned about? Will I have long-lasting effects of taking the 2 triptans too close together?

I am sorry to hear about your terrible chronic migraines. I cannot give you any specific advice, but you can learn from the experience of over 100 people who have commented on this post.

I have been a chronic migraine sufferer for almost 40 years and things are worse now that ever. I have been taking Zolmitriptan and other triptans since the 1990’s and over the years my migraines have steadily got worse. I am now taking a triptan every day just to try and function. It seems like one long migraine that never goes away and the triptan gives me a few hours pain free before it’s back again. I have seen many specialists and consultants over the years and they all want me to go cold turkey and come off the triptans. I have tried so desperately hard but it’s proved impossible. I have recently been warned that I risk having a stroke if I carry on and if I do I will then be taken off the triptans. I do not have cardiovascular problems at present. I live in hope of a day free of migraine as my life is crippled and I cannot go out for long. I find I don’t take the triptans soon enough as I’m always trying to not take one but it doesn’t work, the sooner I take one the better things are but now I’ve ended up taking one every 24 hours. Preventatives don’t suit me and have so many horrible side effects. I am at my wits end and feeling so desperate. My life is a mess and I cannot plan anything at all, I just watch other people leading theirs. I am wondering if it would be best just to take a Zolmitriptan at bedtime every night and ensure that I am migraine free the next day rather than wait until the pain and nausea starts and it ‘s too late. Please can you help me. I feel there is nobody in the world who can help me, I feel so alone with this problem and I am desperate. What shall I do?

Sumatriptan (Imitrex, Imigran) does not cause neck pain, whether you take 30 tablets a year or 30 tablets a month. However, neck pain is a common accompaniment of migraines. Patients often ask me if the headaches are causing their neck pain or the neck pain is causing migraines. Neck pain can indeed trigger a migraine but occasionally, migraine can cause neck pain. I see many patients with head-forward posture (the ear has to be at the level of the shoulder and not in front of it). This is often due to prolonged sitting in front of a computer or texting. Proper ergonomics, as well as neck and upper body exercises can strengthen muscles and restore normal posture. Strong muscles are much less likely to go into spasm and cause a headache than weak ones.

Dr. Mauskop – is it possible that Sumatriptan is the cause of my painful neck? My neck gets swollen up and gives me what I think are tention headaches. I started using Sumatriptan about 4 years ago for migraines and have been suffering neck pains about the last two years. I cant get comfortable when I sleep. I hope its not a side effect of the Sumatriptan because that has been a life saver ever since I started taking it. I have been averaging around 30 100mg tablets per year although this year I am above that average. thanks

No, there is no evidence that daily triptan use causes cardiac problems or strokes. It is true, however, that patients who have preexisting cerebral, coronary, or peripheral vascular disease should not take triptans because of the risk of strokes, heart attacks, and loss of a limb (though the latter has never been reported).

I have daily migraines, and have been taking triptans daily for several years. Yesterday, my neurologist, after hearing I was under increased stress because my husband just lost his job, decided that I should be limited to 15 triptans a month, and to deal with the rest via biofeedback and “mind over matter.” She claimed that triptans cause stroke and cardiac problems. I’ve been reading that MOH is not proven, and that complicated MOH (I have depression and anxiety and also take effexor and klonopin) doesn’t necessarily get better with removal of triptans. I’ve been to almost every neurologist in Boston, and had almost every medical and non medical intervention. Is there evidence that daily triptan use can cause cardiac problems? I saw your comment about the lack of evidence for triptans causing stroke. Thanks for your help. Trying to figure out what to do next, and your comment could help.

Fortunately, there is no association between migraine headaches and hemorrhagic stroke. Here is a recent study that confirms this. Sumatriptan and ergotamine also do not cause hemorrhagic strokes. Based on millions of exposures to these drugs, neither sumatriptan nor ergotamine have been found to increase the risk of hemorrhagic strokes, although single case reports have been published.

I have had headaches since my teenage years. Never really severe. Finally around age 40, my doctor diagnosed me as having migraines w/o aura….mostly due to the frequency rather than the severity. (I wonder if my headaches aren’t actually migraines but something else — sinus maybe.) She prescribed sumatriptan which I continue to take at 25 mg. PRN. My headaches occur 15-20 days a month, usually in groups of 3-4 days with 2-3 days in between. The 25 mg. sumatriptan works 95% of the time to get rid of the headache for the day. The other 5% usually require a second 25 mg. to get rid of it. Over the years, we have tried preventative meds: topomax, verapamil, propanolol, magnesium supplements. The only one that helped at all was propanolol, which caused me to gain much weight. I have worried about how often I take the sumatriptan, and am somewhat relieved to hear that it most likely will have no long term negative affects. It has never been suggested to me to take this as a preventative medication but I may look into that with my doctor. My mother had migraines as long as I can remember and she took Wigraine (ergotamine) pills for many years. I often feared that the long term use of Wigraine pills contributed to her hemorrhagic stroke at age 68 and ultimate death (again stroke) at age 75. No one has ever suggested that to me, but it continues to concern me that the medication may have weakened her blood vessels. I have also wondered of the correlation between the actual migraine headaches and hemorrhagic stroke.

Chances are very small that sumatriptan will stop working after many years of being effective. Actually, the usual dose of sumatriptan is 100 mg rather than 50 and with 100 mg people often do not need to take paracetamol (acetaminophen in the US) with caffeine. Yes, I do recommend regular physical exercise to keep the heart and the rest of the body in good shape. Also, I recommend to most of my chronic migraine patients a trial of Botox, which is safer than any drug and is effective for 70% of patients. The only drawback of Botox is its cost, but it is covered by most insurance companies in the US and the National Health Service in the UK.

I am taking Sumatriptan (50 mg) on a daily basis for the past 3 years. Before then, I took Imigran almost daily for years.
I have tried several prescribed migraine preventatives such as Gabapentin and Propranolol for at least a year each.
In the present, if I don’t take Sumatriptan, migraines make me disfunctional.

Sumatriptan (50 mg) takes 1 hour and 15 minutes for me to start working. This is often the most difficult and frightening time for me where I find myself contemplating ending my life if it would not work, despite having a most grateful and wonderful family life. There is nothing else I know that works.

I often take Sumatriptan with Panadol Extra (which is paracetamol 2x500mg and caffeine 2x65mg) if the migraine/cluster also includes an overall headache. Unfortunately paracetamol without caffeine doesn’t do anything for me.
I rarely drink coffee by the way.

Ibuprofen is a migraine trigger for me (I don’t know why but this seems hard to believe for some). I have countless things that trigger migraine, such as foods, social situations, anything alcohol incl parfume, vitamine B and C, watching a movie in a cinema, dreaming, the list is very long! I am scared going to sleep as I often brutally wake up in excruciating pain middle in the night following a vibrant dream.

I started having my first migraine attacks around the age of 9. Back then I had migraines once every 2 months on average with chronic headaches in between.
I was told by doctors, teachers and friends I worry far too much and that I was going overboard with it.

I am now 53 years old and to my amazement I am still alive having endured so much pain on a daily basis. I have annual full-medical checks which cost me a personal fortune and the fact is, according to all the medical investigations thus far, I am in excellent and even “examplary health” (not my words). I am even told I beat the nation’s averages on all health aspects covered in the report.
I live in the United Kingdom (but am not British). I am 1.82m tall and slim build (65 kg), virtually no fat on me. Could use a bit more muscle definitely. I don’t drink alcohol, never smoked and avoid an ever growing list of foods (and junk) that trigger migraines. I watch carefully what I eat and drink. I walk, cycle and swim when I am able and am grateful I can work flexible hours part-time from home. Despite a so-called magnificent health record, I am living in pain for more than 40 years. I worry that Sumatriptan is going to fail my heart during a physical (sportive) attempt in between migraines, which I would like to improve. I also worry that Sumatriptan might stop working or not be in my reach one day.

Thanks for your response Dr. Mauskop. I will talk to her about a 2nd round of botox but it was so painful for him I’m not sure I would want to do it again without a guarantee and I know there is no guarantee. I just don’t get the Triptan rebound thing…I was reading a study about daily Triptan use not being harmful and it said that they reviewed patients first for the study they did to see if they were in a Triptan rebound stage and they didn’t put them in the study – my question is if they don’t cause rebounds why would they review them for rebounds? Does that make sense? How would one know if they were in a rebound state from Triptan use? We are going to try accupuncture next week, I hope it helps some. The thing is my sons headaches start off at a 2 or 3 and if you don’t react quick they progress until he is in so much pain he is vomiting. It is never a dull constant pain it escalates fast, these days I don’t wait til it gets worse, I just give the Triptan on the onset of level 1 – 2 pain so that the day can go on as normal. I just have to stay hopeful that one day these will go away. One can only hope 🙂

Unfortunately, I cannot say if this is the best treatment without seeing your son. Yes, boys are more likely to outgrow their migraines than girls. I would also ask his doctor about repeating Botox injections since it sometimes takes two treatments to see a significant improvement.

Hi Dr. Mauskop, in regards to my comment on 11/7 or so and your reply on I think 11/20 – yes the Triptans are working very well for my 12 year old son but like I said, they have become daily in October. I think since than he has gone maybe 3 days without getting one. They are hitting about ever 24 to 38 hours, sometimes within a 12 to 17 hour period but rarely. You asked why my son doesn’t go to school, when we took him out 2 years ago, he was in a chronic state and he was getting them so often he was missing too much school work and it was putting a lot of extra stress on him and our family. I thought by taking him out and homeschooling it would take the stress away. He had no problem with homeschooling, he goes to a homeschool campus near us 2 days a week for a couple of classes so still gets a lot of social time in. Plus is in a band he is a drummer and orchestra (crazy how the music and loud noise don’t bother him). His migraines are usually on one side or all around the top, he doesn’t have any other symptoms) Anyway, since these have been daily our headache pain specialist has tried a lot of preventatives, they didn’t seem to help and came with a bunch of side effects – Topomax, nadolol, Gabapentin to name a few, the miracle drug for a while was Cyproheptadine but that seems to have stopped working. He also tried the 3 or 5 day heavy steroid treatment with no help. I didn’t give him his Triptan one morning when I I was too scared to give it too often and ended up in the ER, horrible pain and vomiting – the cocktail they gave in the hospital never brought it completely down. However the Triptan always does and did that day when I brought him home from ER. Anyway, my big scare is that he is in the rebound mode – but with listening to my headache specialist and you, I feel fairly comfortable giving the Triptan daily – normally he never needs another dose in the same day (maybe once a month he will) and his Aleve isn’t having to be given everyday either. If this is a rebound mode, I don’t even know if I care anymore because to me he is getting a quality of life and pain is aborted quickly. I just don’t get why everyone is on me in the Migraine facebook community that says you can’t give Triptans more than 2 times a week! They literally have their kids in home in 24/7 pain because they won’t give the Triptan. My specialist even said she went to a symposium about 2 months ago and it was documented recently that preventatives are not really working on kids and she was surprised to see how many other neurologists give Triptans daily if that is all that works. I guess I don’t even know the question I’m asking, I just want some re-assurance that I’m doing the best thing. Also, I wonder if this recent daily migraine has to do with his age and hitting puberty soon? Also, have you heard that boys grow out of them more often than girls? Thanks so much for listening. Your website has a world of information in it and I appreciate it so much 🙂

Yes, if you can go 5 days without sumatriptan, you are suffering from frequent migraines and not medication overuse headaches.

I have been on daily triptans for several years and with far fewer side effects than other preventative medications. I have lowered my use of triptans by taking supplements that reduce glutamate in the brain and increase GABA (oxaloacetate acid and gastrodin).

After years of research and my own trial and error experiments, I have concluded that keeping your brain out of an “excitatory” state is what reduces or eliminates migraines. For example, amitriptyline works because it raises serotonin (calming neurotransmitter) and blocks histamine (excitatory neurotransmitter). Anti-seizure medications work by blocking glutamate.

Everything these preventative medications can do can easily be replicated through supplements with better results and fewer (if any) side effects. The only prescription medication that has done a wonderful job for me are triptans.

I have chronic migraine and have tried everything – beta-blockers, topamax, botox, meditation etc and still get at least 3 days out of every week maybe more with an attack that is only relieved by sumatriptan eventually. Sometimes it takes only one does other times several. I have been concerned for a while that my headaches are caused by triptan overuse syndrome, but as sometimes I can go 5 days without using it. Does this mean it is not the sumatriptan. I am 61 years old – the migraines have been getting more chronic as I’ve got older. I have been using sumatriptan for 20 years now.

Yes, I’ve had a number of patients taking a triptan once or twice a day for their chronic migraines without loss of efficacy for many years.

Thank you so much for your reply and for listening. At the end I was taking Relpax 40 mg daily to every other day, and sometimes another Relpax a few hours later the same day if it didn’t work. I told myself that at that point – if I didn’t stop – they were just going to stop working since logic told me that the slope would continue – i.e. that I would continue to need more and more. It would help me to know,
Can a patient maintain, or plateau at that level, indefinitely? Everyone told me that wasn’t possible, and logic made me agree, that like any drug that you seem to need more and more of – eventually the bottom falls out. I thought that had happened. Maybe it didn’t. Maybe my best quality of life could be taking a triptan every night before I go to bed – and one any time I feel a headache. Or just as needed, period. Maybe that could go on indefinitely? My quality of life is not as good as it was before going off of the Relpax. At all. Thank you so much for posting this forum.

Unfortunately, I cannot give anyone individual advice without seeing them as a patient first. You should discuss with your doctor pros and cons and try to figure out when the quality of your life was better, on or off the triptans.

I’m 56 and have been on triptans since they came out as imitrex injectable only. (i.e. forever) Initially I only needed them every few weeks. Relpax was my saving grace as I went through menopause. But over a period of 5 years or so – I needed more and more – it went from needing it once or twice a week to 3 to 4 times a week to damn near daily – and then needing extra doses because one didn’t work. I convinced myself I had to go off – and that even if I didn’t – it was going to stop working for me, as I now needed so much to make it work. It took 3 to 4 MONTHS of no triptans for my brain to settle into an every 2 week migraine pattern again (my headaches last 3 days and are completely disabling due to constant vomiting). During that 3 to 4 month triptan withdrawal period, no preventative worked, and the migraines came once a week, lasting 3 days (yup – that’s like no time off) and the vomiting had me in the ER and terrified I would die due to the incredible intensity.
After 3 months of no triptans, Depakote started to work and got me down to migraines every 3 to 4 weeks – sometimes – if I’m lucky. Of course I hate being fat bald and lazy (Depakote) –
I did not do well or respond to Amitryptiline or Topamax – I’m getting another Botox treatment but I yearn for the days when I was on Relpax once a week. That was a life. I’m no longer employable. I’m on magnesium and B supplements. I am convinced all of these years have trained my brain to need triptans.
Going from needing triptans once every two weeks (average back in the good old days) to nearly every day?
And now – if I resort to triptans again (I tried this last year) – I go from taking one every two weeks to once a week to once every 3 days in about 2 months. Bam – back to square one.
I WANT to just take the damn things every day – at least I could live –
IF they kept working for me.
I’m so afraid they won’t, and then I’ll go through 3 months of withdrawal HELL again – I can’t face that.
Which way to go?

What a fascinating blog. Full marks to Dr. Mauskop for his helpful & generous insights. I’m a UK citizen now 72 years old and have suffered from regular incapacitating migraines all my life and until I discovered triptans, (about 15 years ago), nothing I was prescribed was the slightest bit effective in treating the crippling pain that limited my education, blighted my life & blights the life of every sufferer. I now just take one 12.5mg tablet of almotriptan, (as necessary – about five times a month on average), and within 2 hours the mind numbing pain almost miraculously just melts away with no noticeable side effects apart from a slight sore throat. I haven’t noticed any increase in migraine frequency over the years, probably the reverse, if anything.Thank goodness for medical science!

I have been taking triptans daily for 15 years (50 to 300 mg), they are the only thing that work and I have tried every other prescription and supplement and alternative treatment under the sun. In fact, some narcotics like dilaudid make them 100 times worse, if that is possible. I was told 10 years ago I’d die of stroke if I kept taking triptans daily. However I am still alive and well, active, athletic, and not dead yet, and the imitrex allows me to work and function when nothing else does. I find it rather astounding that one kind of drug only does the job, but I am grateful. I was told for years I was suffering rebound headaches, but if that were the case I would think they would become ineffective over time, which is not the case. I am still trying to treat chronic Lyme disease, and hope as I reach this goal I can stop the imitrex as well. Researchers relating chronic Lyme and Alzheimers show significant inflammation in the brain, I don’t know but wonder how much triptans help this, indirectly or otherwise.

If you have more news, research on patients taking triptans long term, please continue to post, thanks.

Yes, preventive therapies are more appropriate for frequent or daily migraines. These include drugs, such as propranolol, duloxetine, amitriptyline, tizanidine, losartan, gabapentin, topiramate, and many other, as well as Botox injections. Supplements can be also very effective and the more effective ones are magnesium, CoQ10, Boswellia, riboflavin, and feverfew.

I used to take Maxalt 10mg and for almost 2 years i am taking Sumatriptan 50mg and it seems my migraines are getting worse. Is there any other medicine i can take to help me cope with my migraines? It’s really hard to work and look after my family. I have this migraines since my 14th birthday.
Any help?

I would repeat Botox, but ask the doctor not to inject Neck and shoulder muscles. Naratriptan is definitely a better drug than Excedrin because it is much more effective and is much less likely to cause rebound (medication overuse) headaches. We often recommend combining naratriptan or any other triptan with naproxen (Aleve). Aleve is also much less likely to cause rebound headaches than Excedrin because it is caffeine in Excedrin that causes rebound. I would also try taking magnesium daily, preferably magnesium glycinate, 400 mg daily (there are many posts on the blog and articles on the main site on magnesium).

Hi! I have been suffering of severe headaches for over a year. I went to a headache clinic in Miami and they did everything. Therapy, accupucture, preventing pills such as gabapentin etc and the only thing that works is naratriptan. I did botox two month ago and after 5 days I started getting a stiff neck, and I think a pinched nerve and muscle spasm on my shoulders. I have been in pain for two months and muscle relaxers, anti-inflammatories, even a nerve block between C4-5 did not work… everything causes me headaches at night when I rest my head on a pillow. Is it possible Botox was the cause? I started to take excedrin again because when I use a flat pillow it helps my neck but gives me headaches. I am desperate, I saw neurologist that are against naratriptan more than 3 times per week, chiropractor, orthopedist and pain doctor. Nobody can help me to aleviate the pain in my shoulder , neck that lead to headaches ( most of the time at night). Any suggestion is well appreciated. I am a highschool math teacher and I missed my regular life. Thank you Doctor!

Actually, I recommend whatever triptan works the best. Frova is rarely an option because it’s not available as a generic and no insurance will cover a large number of pills, if any. MOH is a rare occurrence with any triptan. Sumatriptan is the cheapest, so it’s the most commonly used one.

I just discovered this site doing some google searches to try to get ideas for my chronic daily headaches. This article is so comforting to me, because I take Triptans far more often than the recommended 3 days per week. I’ve been under so much stress at work and am being reprimanded for missing so many days (Not working is not an option for me) that I feel like I have to ‘break the rules’ in order to show up every day and do my job. Which is teaching Pre-K students as a language specialist, so accommodations like a quiet, dark room are not exactly an option.

I mentioned daily triptans to my headache specialist and she’s actually not against them, which is a fantastic surprise. She is advocating using the long term triptans if they are for daily use…Frova and Amerge vs the Zomig I’ve been usually taking. I think it is because they are less likely to cause moh but I’m not sure. What are your thoughts on this?

Migraine headaches are much more common than cluster, and even more so in children. Usually they are easy to tell apart – cluster headaches are strictly one-sided, begin and end suddenly, last 30 minutes to 2-3 hours, and are accompanied by tearing from one eye and nasal congestion.

I am not clear, if the triptans do help, why can’t he go to school. Triptans can be given twice a day and they rarely cause rebound headaches. Yes, Botox can be very effective even for rebound headaches and it does a couple of weeks to start helping. The first Botox treatment may provide only partial relief, but each subsequent treatment could be more effective than the previous one.

TO TIPPI: My heart goes out to you and your son. I’ve suffered since I was a teen, now 20 years of this. Early 20’s they disappeared only to come roaring back for an episode once every year. It is completely disruptive of life and no one understands the pain unless you have it. It doesn’t sound like your son has migraines. It sounds like he has what I have – cluster headaches. They are far worse than migraines and work differently. Have him try sumatriptans – especially injection ones. For preventative, Verapamil (blood pressure medicine) is very effective in dimming the cycle to where it completely stops. It’s also relatively safe and can be taken in higher doses if needed. If the cycle is very intense, Prednisone (corticosteroid) also works for kicking the issue, but once weaned off the steroid the headaches may come back as the episode was never put down. Between taking Verapamil daily and using the sumatriptan as an abortive, I’m able to keep my life functioning at least. Read as much as you can on cluster headaches. Notice that his headaches probably occur at the same time every day(?). The cluster is an inflammation of a large nerve in the brain called the tri-geminal nerve. He is essentially having nerve pain in his brain. It’s believed to be a dysfunction of the hypothalamus which causes the pituitary gland to release a hormone that causes the brain nerve to flare. Make sure he gets plenty of sun as Vitamin D is essential for hypothalamus regulation and health. Supplement vitamin d capsules are garbage and not real vitamin d. Don’t listen to the neurologists who will throw opiates, tramadol, and everything else at it. It doesn’t work and will make him sicker. Any further questions or discussion, I’m more than willing to help: codog26@gmail.com

My son is 12 and he has had migraines since he was 6. They were always under 10 to 12 a month and could always be aborted with Triptans – Zomig nasal spray or Maxalt pill. H would take a triptan anywhere from 2 to 4 times a week. well, as of 33 days ago, he has had a headache every morning and we have used a triptan for each time – never have we done this before. To us, his quality of life is more important. Our migraine specialist is ok with this while she is trying to find a new preventative that will work. His Cyproheptadine stopped working seems like or maybe this is a hormone thing since he is about to hit puberty? We are so saddened. He has actually been pulled from school and homeschooled now so that we can keep up with his academics on our time frame. My question is, I do think these have turned into rebound headaches possibly but I’m not sure and, can you ever get out of a rebound or chronic daily state without having to do anything drastic? We just don’t know what to do from here. Thanks in advance for replying when you have time 🙂 We are also hoping a recent Botox treatment will help but it has been 5 days and we haven’t seen a sign of improvement, I do know it takes maybe 12 to 14 days to kick in.

These preventive drugs for migraines are indeed very promising and I just wrote a post about the CGRP drugs.

Thank you doctor for taking the time to reply, and your kind offer. I will be having a head/neck mri next week and will share this with my doctor on the follow up visit.
Thank you again.
God bless.
Jack Wehr

It is true that most neurologists and particularly headache specialists have strong negative feelings about Fiorinal and Fioricet, especially with codeine. Caffeine, which is an ingredient in these drugs and codeine, both can cause rebound headaches (so called medication overuse headaches). However, if a patient has been taking the same amount of these medications for a long time without any evidence of worsening of their headaches and without any signs of abuse or dependence, there is no reason not continue such treatment. So, in fact this is a reasonable exception to the general rule of avoiding these drugs. Feel free to show this post to your doctor and he is welcome to call me, if he’d like.

Dear doctor, thank you in advance for your time and help. I have had 2 failed lower lumbar spinal fusion’s, with hardware about 18 yrs ago. I now suffer horrible, debilitating migraine, cluster, and tension headaches. No preventatives have worked, however daily imitrex, and a judicious amont of fiorinal with codeine 30 a month. My internist of 14 yrs has blacklisted the fiorinal based on a meeting he attended. He said the only way he would be open is if an expert in headaches advised this is reasonable. Would you mind giving me your opinion? Prior to is I had been using this med successfully for 14 yrs. No history of abuse of any kind.
Thank you.
Jack

Thank you for your comment. What are your thoughts about the new trials relating to monoclonal antibodies for the prevention of migraine. I have heard promising news and am eager for new options.

I cannot provide individual recommendations to patients I haven’t seen, but speaking in general, Cambia can be more problematic than Relpax. Like any other NSAID it can cause stomach ulcer, bleeding, etc. Steroids are potentially even more dangerous and I prescribed them as a last resort. I do have patient who take steroids two days a week each month, but not more often than that on an ongoing basis.

I just stumbled across your blog and website. At 57, I’ve had migraines for 40 years and chronic daily migraines for 10. Relpax is the one drug that I can almost always depend on, but I have worried about daily use. I’ve worked with my neurologist and PBM to obtain 36, 40 mg/mth and struggle to make it through the month as it’s not uncommon to require 2/day or occasionally 3. I sometimes combine it with Cambia before bedtime, and then I generally wake up refreshed and without a headache until about 4 PM. My question is whether there is a concern about the daily triptan use – your comments suggest no. Also, is there a concern with regular Cambia use in conjunction with Relpax? I do that less frequently, but am not clear on any adverse results or maximums. Finally, I get great success wtih taking double packs of steriods. I start with 5/day and then the second pack 5/day; followed by dropping to 4/day….. down to none. By the time I drop to about 3/day, my headaches are gone or nearly so and I can get up to 2-6 days headache free. Is there a “safe” level that can be taken on a daily basis with similar results? Thank you for your input!

Thank you for your tip. I also refer patients to GoodRx.com, which offers discounts at local pharmacies in the US.

I am a physician and for those patients who do well on daily sumatriptan, I FAX an rx to a Canadian pharmacy) universaldrugstore.com. There they can purchase 96 of the 100 mg tablets for $137.00 If they prefer Treximet, I send them to Wal-Mart for generic 500 mg Naproxen where 180 tablets are $10.00
This home-made Treximet (sumatriptan + naproxen) costs about $1.30 versus the Big Pharma retail of about $95.00 per tablet

My insurance company allows for 30 6 mg sumatriptan injections a month. Are they ok to use daily like I would with a pill? Imitrex by shot is the only triptan that’s ever worked well for me. I have Ehlers-Danlos and CSF leaks as well, not sure how much that complicates things.

How can I get the insurance company and my doctor to get on board with this? I take Rizatriptan for all my bad headaches (sinus, tension, cluster ect) and it works every single time. I rarely have to take more than one at a time but I do take about 5 per week. Now…the insurance company and my doctor have decided that this is too much. Doctor put me on Nortriptaline but I have not taken the first pill. The Rizatriptan has worked and worked well so why can I not take it every day for every headache if it is working. As for the rebound my doctor talks about, I also take 800 milligrams of ibuprofen a day (along with prednisone and a low dose of buspiraone) for RA. The rebound could just as easily be coming from that. My original doctor had no problem with me taking that much but he retired and I had to find a new guy and the new guy only wrote one month supply.

I have had migraines for 25 years, currently 30 per month. I take 2.5mg of Zomig almost daily and sometime have to take a second dose if the migraine won’t go way. I just had my 1st round of botox six weeks ago but now my neurologist wants me to stop taking my Zomig cold turkey and take a tapering treatment of Prednisone for 6 days. She’s convinced my migraines are due to the rebound effect of me taking Zomig daily. Do you have any experience with using Prednisone to get off of Zomig? I am scared of going cold turkey off of Zomig and not thrilled with having to take a steroid. I wish my neurologist thought like you and just allowed me to finish at least 3 rounds of botox to see if that can reduce my migraines or not and then allowed me to take my Zomig as needed (even if that’s still daily).

I am a sufferer of daily migraine headaches. I remember having migraine attacks even when I was 4 years old. Triptans were not available back then. If it wasn’t for these miraculous pills, life would be unbearable for me. I take 1/2 tablet almost daily. I suggest that we sufferers spend less time on computers because steadily looking at a light source for hours (monitors in this case) triggers migraine.

What a relief! Just got back from vacation and had ongoing episodes of postural related migraines at night. Mine begin when I’m in a supine position (without wedge) and dissipate when upright. It’s not happened in a long time but it’s not new either. My neurologist at the time suggested the wedge and pillow and it tends to work. But this trip we were up and down in elevation which I think may have contributed to the headaches. So. I began taking 1/2 of 2.5mg Naratriptin tablet at night. Worked. No headache waking me up and no headache or residual in the morning. On returning home same thing happened WITH the wedge raising my head. So I reverted to taking the 1/2 Naratriptin. I made the decision to continue with that regime with occasional ‘check in’s’ every couple of weeks to see if I still needed to do that. I am 66 and in good health with the exception of Migraines. When I read your article and comments by other physicians I felt MUCH better with my choice of treatment. Years ago I had read that Amerge was being tried as a daily preventative with good results and as long as 1/2 of 2.5mg at night works I am both relieved and rested. Night was becoming ‘not my friend’. Thank you so much for sharing your information.

Caffeine in Excedrin Migraine is the only substance clearly proven to cause rebound or medication overuse headaches. To my knowledge there have been no reports of serotonin syndrome from a combination of typtophan and triptans. Even combining triptans with SSRIs rarely, if ever causes severe serotonin syndrome.

Thank you Dr. Mauskop (and all my fellow sufferers for sharing…) for all your contributions.
I too have daily migraines (no doubt many may also be MOH,or rebound,et. al.) and take daily multiple doses of sumatriptan and generic Excedrine Migraine. Just recently started propranolol (Inderal) 10mg as a trial preventative. My question is regarding the risk/safety of taking supplements which contain 5-HTP or tryptophan since I read that those substances are contraindicated to triptans (i.e. may cause “seratonin syndrome”). I’m very anxious to try these supplements but am afraid of the possible dangerous interaction.

I eagerly await and will be most grateful for your response.

I have found an excellent source of sumatriptan in Canada. I use North Drug and buy it online. It is only about $1 per 100mg, and I use 1/2 of one daily. It’s the only way it works reliably, and I have no rebound problems as long as I allow myself to use it every day. I have been with sumatriptan since the clinical trials in NY about 25 years ago.

Thank you so much for your kind reply. If only could stop worrying, worry in case I get migraine, the fear of each day overwhelming, worry if the tablet will work, worry that I may be taking too many, worry my neurologist will want me to come off triptans as he says the amount of migraines I have is caused through medication overuse, and I know that I cannot live without an abortive treatment, mind you I am 64 , so about time I stopped worrying about migraine and its ruination of my life, so your article on the evidence of overuse not being verified I found interesting, if I could I would come to your clinic, but I live In Suffolk England, but will recommend this site to friend. Many many thanks.

Hi Denise,
Yes, you should stop worrying because worrying does not help anything. However, I cannot guarantee anyone, especially without first seeing them, that Zomig or any other migraine drug is totally safe. For example, people who have had a heart attack or suffer from coronary artery or peripheral vascular disease should not be taking triptans. As far as taking a triptan nightly, some of my patients do find that it prevents morning or middle-of-the-night migraines. Some need half the usual dose and some a full dose.

I am in tears reading this blog, I can’t thank you enough, I have had chronic migraine for 37years, worsening these past 2years, I have been on zomig rapt let 2.5mg for few years now, and currently am taking 4/5 per week, every week, and live in constant fear of migraine, mainly because the doctors say not to take more than 2 per week, but when I have to go through a migraine, the pain is excruciating, and start being violently sick about every 30mins for 15 hours and along with that terrible pain, which only migraneurs know, I honestly want to die and have to say have had thoughts in that regard from time to time, as I am sure others have to. So I am not sure if the increase in amount of migraines is due to zomig over use, always wake with it about 5am. Due to see neurologist again on the 16th, but like many have seen so many during the years and nothingmuch changes. Your comments have reduced the stress of tablet taking, am interested in taking low dose at night. Should I stop worrying about how many intake and just think at least I can have a life.

I am a 59 year old female who has been suffering with migraines for the past 5 years. They are progressively becoming more frequent – last month I had 20. I have seen 3 Neurologists over the past 5 years who have tried Gabapentin, Nortriptyline, 2 sessions of Botox injections and nothing has helped. I have had 2 MRIs and my family doctor has scheduled another to see if it shows something we’ve missed. I have even spent money out of pocket to try some natural supplements for hormones and magnesium and vitamin B2, plus other supplements that have been tested for migraines. Three years ago I was given a prescription by a wonderful Emergency doctor for Riza-Triptan. It has been a miracle drug for me!

Up until now my insurance coverage has only allowed me to have 12 tablets every 30 days. My Neurologist and doctor also feels this such be sufficient. Now, because I have a solid history with this medication my insurance company has deemed this a “maintenance drug” for me. I have an appointment next week to talk to my doctor with hopes that he will agree to increase my prescription to 30 tablets every 30 days to eliminate the stress of having to choose when to take the medication and when to suffer and end up going to Emergency for pain relief. When the 12 tablets are gone, that is where I have to go for help.

I am taking an article with me to my doctor that I found, written by you, saying you have some patients that would qualify to take Riza-Triptan on a daily basis, once everything else had been tried first. I have no other health issues – I don’t smoke, drink, I walk every day and have even adjusted my diet to eliminate some of the foods that are common triggers. What would you recommend I say to my doctor to convince him that increasing my medication would be the best thing for me, both physically and emotionally? Surely quality of life is important too.

Thank you, Dr. Meyerson for your comment. Your experience will give further reassurance to people who have no other option but to take a daily triptan for their chronic migraines.

I have almost daily migraines, I failed preventatives. I had botox it worked well but I still had headaches then when it was wearing off my headaches were extremely bad and daily. I have been taking 1/2 of 100 mg sumatriptan in am and 1/2 in pm. My headaches are well controlled. If I am late or forget my medication I get a migraine that I need to take 1/2 – 1 pill to resolve. Every once in a while, I will forget a pill and not have a migraine. I have been doing this for almost 6 years. I also buy them at costco and prescribe them to my patients with daily migraines. I have been able to avoid using narcotics and barbiturates for those who have also failed other prescribed treatments.

I feel so much better after reading this! I’ve been having chronic migraines for about 3 yrs. I always feel so guilty for taking so much medicine! I have tried so many preventive options including Botox twice. What’s everyone’s advice on how much to take of the CoQ10, magnesium, and vitamin D? How long did it take to see improvement? I think I’ve tried this before but I’m going to try again. I’m so happy I found this blog!

I cannot give specific advice to people who are not my patients. But in general, I would first ask your doctor to check your RBC magnesium level (not serum, which is inaccurate). If Botox helps, it is safer even during during pregnancy than any drug. Fortunately, most women stop having migraines when they are pregnant, but if they persist, no drug has been shown to be completely safe. On the other hand, having a severe migraine has also has a negative effect on the fetus. Triptans belong in pregnancy category C, which means that there is not enough data to pronounce it safe, but aspirin, ibuprofen, naproxen are definitely contraindicated in pregnancy. Fioricet is popular with some obstetricians, but it is not any safer and is less effective. The bottom line, if migraines are severe and a medication is needed, I usually prescribe a triptan.

Hi, thank you for your really informative blog Dr. Mauskop ! I currently use zomig approximately 4 x p/week and have just had my 3rd botox treatment. We’re thinking about having a baby and I’m wondering about your thoughts on using triptans during pregnancy ? I know you have written about this elsewhere, however i’m worried about the current frequency that i take zomig. My current neurologist is very risk averse and advises against any use, however my doctor is more inclined to say that I should use them if in pain.

What a relief to hear that long term use of triptans may be safe. I have chronic migraine and take triptans for about 15 days in each 28. I take one tablet and they work well – by evening I feel better. However the next morning the migraine almost always comes back. I stared to take a quarter of a Maxalt (rizatriptan) tablet before bed and have found that this works very well and I wake up fine. I can exercise and live a normal life. This way I take a lower dose overall but have been worried about the daily use issue.

Shame, I live in Ohio. I will have to look into that. I have had good luck before with Magnesium, CoQ10, and vitamin D.Really, more supplements have worked than prescriptions. Thank you so much for your replies. It gives me some things to take to doctors here.

I can do a telephone consultation, but since I am licensed only in the state of New York, you’d have to live in New York for me to do it. Another supplement to consider is Boswellia; here is my blog post about it.

Well what you are saying mirrors my thoughts. I sometimes get some medicine implicated headaches but they hit after sinus infections when I desperately try to use migraine medicine to ease my sinus pain. My new neurologist is asking insurance for Botox. He also wanted me to stop all abortive a minus twice a week Norco and maybe steroids as well as start verapamil as it is on the short list for what hasn’t been tried. The best treatments have so far been CoQ10, magnesium, vitamin D, omeprazole, and Inderal. All gave me a 50% reduction for 3-6 months. The sinus infection and pain issue really makes things worse as it triggers migraines. I had surgery and it helped but hasn’t cleared the infection up perfectly. I will try the Imitrex alone on whim and see if pre dosing or twice daily will work without fiorinal. I hate the grogginess of Norco and it really does very little for my migraines. Neither does Percocet. Just makes me sleepy.

Do you ever do video conference doctor visits? We have no headache clinic here and on my income a long distance clinic simply won’t work. It’s bad enough I need to call my new neurologist and beg to postpone withdrawal due to work conflicts so I don’t loose my job! Thanks for the ideas and reply. They mean a lot. Blogging takes time and I appreciate the gift of your time!

The only way to tell overuse from chronic migraines is to stop the offending drug for about two weeks. However, since you have periods of up to 3 weeks without headaches and without having to take Imitrex or Fiorinal, chances are this is chronic migraine and not medication overuse headache. However, Fioricet is definitely associated with rebound or medication overuse headaches, but triptans have not been proven to do that. So, you may want to try taking only Imitrex, even if you have to take it twice a day. Norco, which is similar to Vicodin, and other narcotic pain killers can cause not only medication overuse headaches, but also addiction (there is some addiction risk with Fioricet as well).
You are right in that taking a triptan daily is a lot better than living in constant pain. Obviously preventing headaches is better and if you haven’t had Botox injections, I would ask your neurologist to do that next.

I have had migraines since 1994. They started out at 6-8 days a month. I now get 15-30. Sinus infections seem to play in as I am better when colds and allergies stay away. I had been using 100 mg of imitrex and a fiornal tablet. My GP left practice and my new doctor didn’t approve. I have been on 20 or more preventatives with no real solution. I do get periods of 1-3 weeks headache free a few times a year. My neurologist is cutting off my imitrex and fiorinal. I am terrified. It is the only thing that has ever worked. For the most part I wait and if my pain hits a 5/10 I take it. How do you tell chronic migraine from overuse? Are frequent Triptans really worse than constant pain? Where do I go next? How do I survive without an abortive for 3 months? I was told I could use norco twice a week but it doesn’t help the migraines only the sinus pain.

In the US leading migraine specialists also strongly advice against using triptans more than twice a week, but in private many admit that they have some patients who do well on a daily triptan. Of course, we also have many neurologists who are adamant about not prescribing more than 9 tablets of sumatriptan or another triptan each month. I think they are wrong in letting their patients suffer without offering an alternative treatment that is effective and does not cause significant side effects.

Yes, I still have patients for whom daily triptan is the only option that allows them to function normally. As I mentioned in the blog post, this is not the first or the fifth option when treating chronic migraines, but if a patient fails Botox injections and several preventive drugs and if triptans are effective, there is no reason not to let him or her take triptans daily, or more often than twice a week.

Very interesting! Here in Germany the leading migraine specialists all warn rigorously against taking more than 10 triptans a month. I always felt that this put a lot of pressure on the patients. As this article is from 2012 – is it still your opinion that there is no clear evidence that frequent/daily triptan intake leads to more migraines or headaches? Kind regards, Fran

many preventatives with terrible side effects and about 17 to 20 migraines a month that occur in the middle of night I felt I was on the way to a physical and emotional breakdown. I have seen one of the most renown migraine specialists for 12 years with a worsening of frequency in past 5 years. After finding this web site and reading Dr. Mauskop’s articles I decided to try taking a half of my maxalt before bed for the past week and to my surprise I have gone 4 days so far without a migraine and a good nights sleep. I know my neurologist would disapprove of this approach but this is the best I have felt in 5 years so I will continue splitting maxalt and may be traveling to New York to see Dr.Mauskop!!!

Hi
I purchase my sumatriptan at Cotsco and get 3 boxes of 9 tablets for approximately $50
No hassle or arguing with the insurance company. I myself need to take them almost daily so I can refill when I want and not be told by the insurance company it isn’t time.
You don’t even need to be a member to buy from them.

Drug pricing is a complicated and mysterious process, but the bottom line is that drug companies will charge as much as they can get away with. They also make deal with insurance companies, so your insurer pays a lot less than what the pharmacy will charge you. I checked on GoodRx.com and you are right, the generic 5 mg tablet of Zomig or zolmitriptan costs $13 a pill, while brand is $80 a pill. Is Imitrex or sumatriptan works for you, it is the cheapest triptan – only $1.50 a pill.

I’ve had migraines for 25 years. Started with a few a year, in my 30’s I started getting weekly
migraines. I have been to many Neurologists, including Tampa Migraine Clinic. It has been
decided that because I have failed most if not all preventative measures with pharmaceuticles, as well as strict diet and one cup of coffee a day, exercise and so forth that taking a triptan is the only
way I can function daily (if I need it). I also do Botox. But, in September, 2015, the price of generic Zomig (Zolmitriptan) jumped to double the cost. Would you have any information as to why?
Thank you-

Migraines usually get better after menopause, but during the transition they can get worse. This is the most likely cause. You may want to ask your doctor about getting Botox injections, which may stop migraines and enable you to get off topiramate.

I’ve been on Topiramate 200 mgs per day, and 5 mgs of Zomig (for breakthroughs) for years now. I’m 51, and possibly nearing menopause, though no real signs yet. My migraines have recently increased from 6-8 per month to about 16 per month. My diet is excellent, plant-based, weight is excellent, too. I exercise daily. I do have one cup of coffee per day. I tried quitting for about a year and a half, but it made no real difference, so I went back to it. Other than that, I’m really pristine with the diet. Not sure why the uptick in attacks, but I’m taking the Zomig almost daily, and worried about it. Seems that the more I take it, the more migraines I’m getting. It really does seem like I’m in a MOH cycle. I wake each night between 2-4 a.m. with pain, and take either Aleve (to try to keep from taking Zomig first) and end up taking the Zomig by 6 a.m. so that I can get to work. It clears up the migraine (sort of) and I get through the day, but by 2-4 a.m. it’s back. So, I’m in a bad loop. Can you explain this? This has never happened before. What could be causing it? I don’t take the Aleve every day.

Sean, you can still get 18 tablets of rizatriptan ODT for $38 – I just checked on goodrx.com. This website has saved hundreds of dollars for my patients. You may also want to ask the headache specialist if he would do a telephone consultation. You may have to pay out of pocket but it could be cheaper than the round trip and will save a lot of money. You should also consider Botox injections which could drastically reduce the need for rizatriptan. Botox is approved only for chronic migraine, which is defined as 15 or more headache days each month.

Thank you Dr. Mauskop for replying to my question on WebMD. I still doubt that this will convince my Dr. that needing more than 18 Rizatriptan ODT per 30 days is ok to do as long as I have no strokes or coronary artery disease. I have chronic migraine w/o aura and the only triptan that worked for me was the rizatriptans and even with the generics finally coming available it still is costly even with the discounts, was $30 for 18 for awhile but last 2 times went up to $75 and I may have to use more than one pharmacy for these. Went the vicodin route till they became pointless, that made me seek out a specialist who confirmed it was migraines not just a really bad headache as my Dr. thought so we finally got me onto the riza. I don’t use it daily but I tend to get them in batches of days 2-3 or four then nothing for a few days and he doesn’t seem to get that sometimes it takes 2 to get rid of them depending on whether I wake up to one-the worst-to taking one as soon as I can feel it coming on or I’ve encountered one of my triggers. So, I’ll try to find a local Dr., the specialist is a 230 mile RT and since I last saw him in ’08 he may not remember me but it’s a long hard drive for me. It’s all about finding Drs. like you and the specialist who are well versed in migraines and the medications, how I now envy the people in Europe since I’ve always thought why isn’t this an otc drug, it’s ridiculous and unless you’ve had migraines people have no idea. I’ve been taking ibuprofen for so long plus use Norco for my back and sciatica pain that I’m a bit concerned about what it’s doing to my liver and is one more reason I need the rizatriptan, the sumatriptans gave me migraines and I think that if the riza works there is no reason to try anything else. I’ve got Medicare but not paying for the drug plan yet until it is less than what I pay without it, my other meds have been covered by my WC settlement but they are beginning to try to get out of it even though the judge basically-his words to me-awarded them having to pay my medical needs for my back injury for life. Anyway, thank you again for the reply, it means a lot when you connect with a Dr. who knows what we’re going through. Sean

My top two recommendations are regular aerobic exercise and daily meditation. Magnesium and other supplements can also help. Botox is extremely unlikely to cause an allergic reaction and is safer than any oral drug. Beta blockers, such as propranolol can be very effective, unless your blood pressure is very low.

Yes, Botox is a far safer option than any drug, including Imitrex and even Tylenol.

I am 29 and have 3-4 migraines per week, sometimes more, never fewer. This has been going on for about 5 years, but I’ve gotten occasional migraines since I was 9 or so. I do acupuncture and have tried physical therapy, nuerofeedback, and elimination diets (caffeine for 1 year, gluten, anything tannic). I’ve gone to two neurologists and they both wanted to prescribe medications that made me uncomfortable: Topomax and daily allergy medications. The potential side effects weren’t worth it to me, but I am tired of taking sumatriptan so often. I don’t take it as a preventative, so I am left suffering with the signs of a migraine (blind spots, stiffness in my neck shoulders, inability to focus, and discomfort and pain that I find hard to put to words) and often the headache itself for a while before the sumatriptan kicks in. The whole thing seems to come from stress and is ALWAYS accompanied by a tension headache. A friend suggested Timolol or Propranolol. What do you think? If it seems to root from body tension more than food allergies etc do you have any other treatment suggestions? I would prefer not to do Botox. My mother is allergic and I don’t want to take the risk.
I would so appreciate any thoughts you may have! I will read through these helpful comments above again. Though I wish others weren’t in pain, it’s even helpful to remember I’m not alone!

I am very intrigued by your article and wondering if you can comment on the use of Imitrex by my Grandmother. She is 82 years old and had been suffering from chronic migraines since she was 10 years old. She was raised in a religious household where medicines were not allowed so she has spent most of her life attempting to treat her migraines holistically to no avail. She finally decided that her daily migraines were causing enough pain and suffering that she would go see a doctor about 3 years ago. She was prescribed Imitrex and it worked miracles for her, at first. She started taking it daily because that is the only way it would work but she seemed to build up a tolerance so she decided to up the dose without consulting her physician. She is currently taking Imitrex 3-4 times a day because she says that it is the only way she can make it though the day. Basically she can only function if the drug never leaves her system. I am unsure of the specific dose that she takes but I do know she had to get the pills from Canada to be able to acquire so many pills. Is it okay for her to be taking this much daily? I am trying to convince her to try Botox but she is afraid. I am very concerned that she is abusing this drug but her migraines are so bad she said she would continue taking 4 Imitrex daily just so she can function, even if it kills her. Do you think there is something better out there for her? Thank you in advance for taking the time to read and respond it is much appreciated.

Some reports involving small numbers of patients suggested that 5HTP can help, but unfortunately, it is not proven to prevent migraine headaches. Yes, it is involved in the metabolism of serotonin, but selective serotonin reuptake inhibitors (SSRI) antidepressants, such as Prozac, Zoloft, and Lexapro also have not been proven to help migraines. Other types of antidepressants, such as Cymbalta and Effexor, which belong to the serotonin-norepinephrine reuptake inhibitors (SNRI) and tricyclic antidepressants are proven to prevent migraines.

I’ve been reading comments so similar to my symptoms/nemesis! I am an almost daily user of Sumatriptan -25 to 50 mg. along with 800 mg of Ibuprofen. I have been reading about 5HTP and wonder if I would be a safe candidate for this serotonin-type supplement. I occasionally take a decongestant like Theraflu and .25 mg of Alprazolam when the Sumatriptan/NSAID doesn’t seem to be kicking the pain. Have you ever recommended 5HTP along with relatively low doses of Sumatriptan? I would like to check this with my doctor and would appreciated any history of this possible combination before I see him again. (I, too, have tried numerous “preventative” medications and was on Topamax and Divalproex Sod together for years before they were no longer effective. I am 61, my liver is fine – I have regular, insurance “suggested” blood work and though I tend to be a binge eater, at 5’3″ and 132# I am not considered overweight and do try moderate exercising as extreme exertion tends to increase all pain symptoms. Thank you in advance for your response.

You actually don’t have to worry about insurance companies covering Imitrex or sumatriptan, because the generic version costs $1.50 a pill (find a local pharmacy with the best price on GoodRx.com), which means that if you take 1/3 of a tablet every day one month supply will cost you $15.

After 40 years of just about every pill known to man, I had enough of the almost daily migraines. The only thing that helps is the triptans.
I did something no patient should do, and in desperation tried something that I knew instinctively would work. Since my migraines mostly start in the mornings, and when I know I am going to have one – weather change, or other known triggers to me, I would break my 100 mg Sumatriptan tablet in thirds and take 1/3 at night. It has been a life-saver for me, and has prevented me waking with countless migraines.
I do not taken them daily, but I believe it would be of more help if I did.
I am praying for an indication for daily, low-dose triptan use, so that insurance companies will cover this medication.

So far, after more than 20 years of experience with triptans we have no evidence of any long-term negative effects. It is possible that something will crop up, just like with NSAIDs – they are now thought to very slightly increase the risk of cardiovascular problems (except for aspirin). However, the chance of discovery of a major adverse side effect is slim.

I am a physician who has suffered from migraines since childhood. I have tried all remedies including Botox without relief. I had a lengthy misadventure with opioids and must now avoid all narcotics. I have taken sumitriptan near daily for the past two years with excellent control of headaches and only one true migraine in all that time. Are you aware of any other research related to adverse effects of daily triptan use? I have sadly found the headache literature to be quite limited and laced with opinion and anecdote. Thank you for your post.

Thank you so very much for this blog I am crying with relief. I have lived in fear of taking relpax, sometimes daily, but usually three to four times a week. I tried everything else over the years, so much so that now i can no longer take anything for pain such as codeine or related, can’t take any of the old fashioned migraine drugs, that didn’t work anyway as they all cause such horrendous headaches. I did find that I have severe food allergies and changing my diet removed about half the headaches but still I suffer with Chronic migraines, severe ones! Also antihistamines will give me horrible ones so I have to be very careful and that is bad as I suffer so with severe allergies. Like others have stated, I will go a week or two with nothing then a month with them almost daily. Doctors tell me that I shouldn’t take the relpax so much but I cannot function without it. With the 40 mg tablet and an hour I can live a fairly normal life. Relpax has saved me, truly! My point being though was to thank you for this will help the horrible anxiety I’ve had over this issue. I wish I could tell you in words how bad its been and how grateful I am to have found this along with the comments that have given me support and hope.

Thank you so much for this post! I suffered for decades from migraines that escalated from occasional to chronic/daily. At that point I was taking such large doses of triptans every day that out of desperation I started to take a smaller dose at bedtime. Most nights I would wake up around 3:00 am with a full blown migraine. The first week I had one or two less migraines, the second week two or three less, etc. When I told my neurologist what I was doing he confirmed that this did seem to work with some folks when all other preventative treatments had been tried and failed (I was in that category). My biggest concern was what might happen to me taking regular doses of a triptan – he said that since I have a healthy heart he didn’t know of any other health risks. Like all these meds, I have some side affects when I have to take a larger dose during a migraine. He had no problem prescribing 25 mg of Imitrex for daily use and 50 mg tabs to use ‘as needed’ when I get a migraine. I do OK with most triptans and now that there is a generic for Imitrex it is the least expensive. My insurance has not had any problems with the quantity prescribed. I now get 6-7 migraines per month and most can be stopped within a few hours with 50 mg of Imitrex, tizanidine and rest. In the past I used 100 mg or more per day trying to treat the migraine. My Dr. asked if I would be willing to be a case study for him on the daily use of triptans an I agreed. I wish more doctors were open to discussing this an option for people who suffer horribly with daily migraines and have “run out of treatment options”. I did the math and find I take a significantly lower total dose of Imitrex with this treatment then I did using large doses almost every day trying desperately to get rid of full blown migraines. Thanks for letting me tell my story, I still get looks of disbelief and people who think I’ll develop some horrible health issue from taking daily triptans.

So grateful for all these posts. I really enjoy reading other intelligent people discuss their migraines & various treatments. I’m 42, got my first migraine at 29. Usually left sided, only had 1 aura (without pain). Triggers are menses, sleep disruption, alcohol. Allergies to NSAIDS & ASA. Cannot do beta blockers as I have low end BP. Extended cycling on the Nuvaring eliminates periods to approx 4 x a year, which is a godsend – highly recommend hormonal stability! I’ve done 2 rounds of Depakote over the years, about 6 months each time, & gained about 30lbs each time, & the preventive effect wore off after a few months anyway. Zomig & Topamax made me spacey. Relpax did nothing. I’ve been using Imitrex for almost the entire duration as a rescue drug, but triggers trigeminal neuralgia & overall myalgia/chest heaviness that wipes me out for hours. Recently saw a new neurologist who prescribed Maxalt – wow! Relieves headache with just a sense of tiredness, lots of yawning. Sometimes need to take 2, but last weekend had to take Sumatriptan for a bad one. It was like using a sledgehammer rather than a scalpel, but so glad it is in my arsenal! Feeling all your pain over here.

Yes, thyroid deficiency can worsen migraine headaches, so going to an endocrinologist is a good idea.

This’s is just what I want to read to stop me worrying about MOH. I suffer almost daily migraine which I think may be connected to my under active thyroid medication. I can usually take approx 20 mg of imigran and get relief for 24 hours or so. I would obviously like to find the cause of these migraines. I have tried a few preventatives including atenolol, topiramate, and pizotifen , without success. I have just been prescribed Gabapentin, but am nervous to try it after reading some awful reviews. I am also seeing a Chinese Dr who thinks it’s related to my back and giving me acupuncture and massage to stop the spasming muscles. Finally I have been referred to an endocrinologist next month .. I am wondering about adding T3 supplement.
Your advise would be greatly appreciated.

The way to definitively prove that the daily intake of triptans does not cause medication overuse or rebound headaches is to stop taking triptans for at least two weeks. For many it is not possible because they become disabled without triptans. Sometimes it is possible to get off triptans by trying various prophylactic medications and Botox, but if these do not work and headaches are well controlled with a triptan, there is no reason not to continue taking a triptan daily. There is no evidence that taking a preventive drug, such as Topamax, Depakote or Elavil is any safer than taking a triptan. In fact triptans, often have fewer side effects than drugs (but not Botox).

Thank you for this blog. I check it whenever I start getting anxious about rebound headaches. I have been taking triptans nearly every day for about 2 years. Nothing else has come close to helping, including Botox. If I wanted to definitively prove that these are not rebound headaches. how long would I have to stop the triptans for? A week? It makes me very nervous to think about but most doctors and even the pharmacists keep telling me that what I am doing is bad for me, so I wonder if I should just try to go off and see.

The only way to know if any drug is making headaches worse is to stop the drug. Caffeine and caffeine-containing drugs are proven to worsen headaches, while triptans (sumatriptan, rizatriptan, and other), as well as NSAIDs (aspirin, Migralex, ibuprofen, etc) have not been proven to worsen headaches. There is no reason to suspect that prophylactic drugs (epilepsy drugs, blood pressure medications, and antidepressants) taken daily are any safer than the triptans. The only treatment that is clearly safer than any drug is Botox injections. Botox often allows patients get off their daily medications, be it a triptan or a prophylactic drug.

Thank you for answering questions on this site. I have had chronic daily migraines for decades. I tried pretty much every Rx and non-prescription treatment, both abortive and preventive (too many to list here) and the only thing that ever worked was sumatriptan. I now take it daily and while I may be in the category of patients you describe in this article, I do wonder if I am adding rebound headaches to my “regular” migraines (especially since they often start during sleep now which was not formerly the case). If so, how in the world do I get off triptans? And, if I do abstain from them and still have migraines several times a week (as I did before such drugs existed), how do I stay off them? Neither “going cold turkey” nor an inpatient headache clinic are an option for me.

It is always better to prevent headaches if they are frequent, rather than try to stop each individual attack, be it migraine, cluster or any other type of headaches. You should talk to your doctor about Botox injections and other preventive measures, including supplements, such as magnesium. If headaches resemble cluster headaches, but are continuous, it could be hemicrania continua which usually is treated with indomethacin, but Botox might also be effective.

Thank you for this article. I am currently suffering from a headache that has lasted for two weeks, I suffer from this two or three times a year and sometimes the headache lasts for upto 3 weeks. I have read about cluster headaches and many of my symptoms do match, however it tends to be a constant headache as opposed to several a day. It is not often severe, although extremely frustrating, and sumatriptan seems to alleviate the symptom within 45 minutes. When I wakeup in the mornings it tends to be prevelant and continues throughout the day, I am 24 and otherwise healthy. I am worried about taking sumatriptan daily during these periods, is there anything else I can try? I have suffered from headaches all my life and was always told I would “grow out of them”.

My experience has been exactly as you described. I began getting migraines 1x per month at the age of thirteen. They were horrible and nothing helped but they would abate in 2-3 days. When I entered menopause they became constant and chronic and so severe I several times ended up in the ER with numbness on one side of my body (I was convinced I was having a stroke) intractable pain and reflexive vomiting I could not stop. None of the older medications worked. Then during one visit they gave me an injection of imitrex and I simply felt like I arouse from the dead within 30 minutes. After trying every other migraine medicine known to man, and every alternative approach I could read about my doctor prescribed Zomig 2.5 mgs 2-3 times a day as needed – at the first sign of a headache. For me the Zomig was like taking an asprin is for a regular headache. It made my headache remit usually for about 10-12 hours. I went through the rebound debate and just as you said I just suffered for days with no relief in sight. I have been on Zomig at the dosage for over 15 years now. One tiny pill in the am and one in the pm and I am a normal person without it I am an invalid. It has been a struggle. I got lucky with insurance supporting it for a long time although now I am at risk because the insurance I have had all these years is going away because of Obamacare and I am going to have to convince the insurance company again – I fear they will make me suffer immensely to prove to them it is in there best interest to support this treatment. I have had absolutely no negative effects of the med at this frequency – it has been a lifesaver.

Thank you SO much for this article. I have suffered debilitating headaches/migraines most days for the last 17 years. I am 33 and can’t really remember what it’s like to not be ruled by the pain.

There have been some improvements lately – this year I persuaded a dentist to take out my wisdom teeth, and that has greatly improved the morning mind-numbing headache after a poor night’s sleep. I do clamp my jaw, but was unaware of it, bite guards and the like were of no help. The wosdom teeth were not only rammed right to the back of my jaw with no space, but would also affect my sinuses while I slept it seems, as they were so large and positioned how they were.

Because I have been able to think more clearly, I have been able to start to pinpoint the other headaches/migraines a little more easily without the over-riding pain caused by the wisdom teeth, and I was able to try Imigran (sumatriptan) – previously deemed inappropriate for me. (I’ve been on many other meds, none of any lasting help.) I do get hormonal headaches/migraines, but the rest of the pain has other triggers.

I don’t need Imigran daily, but I would say maybe 5 or 6 days out of 7 on average. I have just had the best 6 weeks in years since starting to use the Imigran, and this article has given me a little hope that it may not be a futile hope that the ability to function without too much pain on a nearly daily basis might continue. I have been concerned about MOH, but given that I have the odd day or days when I am ok and don’t need the Imigran I can’t see how that can be.

So thank you very much. Hope is a very powerful thing!

I started getting severe migraines at 14 and am now 41. I have between 15 and 27 a month. Zomig is my god send and every time a doctor tells me it will kill me I want to scream – I don’t have a life with out zomig. I used to be in emergency for days at a time through out the month being injected with pain killers that didn’t work and anti nausea medication that made me feel horrible and didn’t work.

I also have been trying botox (again) with more commitment. I go every three months for the past year to see if I can at least knock down my count for the month. So far its a guessing game if it is working. I had a few good months with only 14 – 17 then September and October I had more than 25 each month. What I hope I can have access to trying would be the stem cells. I don’t have the money or the balls to fly to a clinic in Mexico that seems to be a bit sketchy.

Is there a place I can check for clinic trials of stem cells and migraines in Canada or US? Thank you for the website and all the information.

There is no connection between the use of sumatriptan, migraines, and aneurysms. Aneurysms can be hereditary and an MRA scan of the brain can detect them.

I was relieved that long-term use of sumatriptan did not cause any harm since my wife has been taking it for years. I am concerned, though, that it may cause an issue with cerebral aneurysm since her mother dyed of one. I have read that this could be hereditary. Is there anything to be concerned about?

I too have been taking Imitrex/sumatriptan for almost as long as it has been out. I suffer daily migraines and have been through every type of treatment there is, including the theory they are rebounds. This medication is the only thing that works and I pray to god there are no long term side effects. I have two small children and worry about it every time I take a pill. However, without them I wouldn’t be able to function. Has anyone else noticed that it can make you grumpy, or is that just my wife’s view? I share in all of your pain.

The reason for the dose limit of 200 mg for sumatriptan is that it was the amount taken by most patients in clinical trials. Originally, when sumatriptan tablets were approved the maximum daily dose was 300 mg, but then it was lowered to 200 mg. One of the triptans, rizatriptan (Maxalt) has a maximum dose of 3 tablets a day, while for the other ones the maximum is two tablets. In Europe the dosages are somewhat different. Eletriptan (Relpax) is available in Europe as an 80 mg tablet and the maximum daily dose is 160 mg. In the US Relpax is available only in 20 and 40 mg and the maximum daily dose is 80 mg. Sumatriptan (Imitrex) and several other triptans are available in Europe without a doctor’s prescription. This, along with the fact that we’ve had 20 years of experience with these drugs, strongly suggests that these are relatively safe medications.

theres always a warning not to take more than 200 mg of imitrex daily. What’s the risk of taking higher dosage,

Most reliable online sources, including Candaian pharmacies will ask for a prescription. A headache specialist is more likely to give you a prescription for larger amount of sumatriptan. To find one in your area go to http://www.achenet.org

Thank you for this article! I have been taking sumatriptan for over 20 years, and it thankfully continues to work almost every time. I have never had any MOH or rebounds. I am going to bookmark this article and show it to people who try to scare me about my medication, I am tired of hearing how “dangerous” triptans are.
My only problem is I keep running out, and I hate the doctors who will only prescribe a few times & then require me to pay for ANOTHER expensive, unneccessary office visit before re-filling or renewing my prescription. How can I find either a sympathetic doctor, or a reliable online source to purchase without a prescription?

Here is a comprehensive article on magnesium on this website. As far as the best type of magnesium, you can read this post, but in general, I suggest magnesium oxide or magnesium glycinate, 400 mg daily with food.

I am 49 and for the last 3 years have experienced migraine attacks with increased intensity and frequency. I use Imigran , at first I would get instant relief with the first tablet but found that over time I have had to increase the number of tablets to clear the migraine. I have now been prescribed with a Metoprolol Tartrate beta-blocker which has reduced the frequency of the attacks but not eliminated them. I was interested in your recommendation for magnesium supplements and have since researched the effects of magnesium. Your article was very informative.

Yes, I’ve seen patients in whom Imitrex and other triptans made headache more frequent and severe. So, rebound or medication overuse headaches probably do occur from triptans, but this is fairly uncommon and has never been scientifically proven, the way caffeine has been. After stopping Imitrex your severe monthly headaches were mostly hormonal since they were monthly and stopped with what I assume is a contraceptive implant.

I’ve had hormonal migraines since age 16, which were infrequent enough (2-3 a year) that I simply suffered through. When I was 30, a doctor recommended Imitrex. At first it worked great, but within a few months my migraines changed, morphing into something they had never been: much more acute and frequent. I stopped taking Imitrex six months later, but by then I was suffering from monthly migraines so bad I couldn’t get out of bed. Have you ever heard of Imitrex doing this? I suffered with this new form of migraine for 20 years before I bypassed neurologic treatments and turned instead to gynecology. A gynecologist put in an experil implant, and I haven’t had a migraine since. That was six months ago.

Botox is more effective and safer than any drug. It is approved for migraines in the UK, so it should be easy to get through your health service.

I would suggest asking your doctor about raising the dose of Cymbalta (max is 120 mg a day) or Elavil. Other drugs to consider are tizanidine (a muscle relaxant), losartan (a blood pressure medicine, and memantine (an Alzheimer’s drug; see my post on memantine).

Some of my patients also do well on CoQ10, 300 mg and an herb, Boswellia (see my post)

Dexamethasone often works in a tablet as well as in a shot. The usual dose is 8 – 10 mg. However, frequent use of steroids (and sometimes not so frequent) can cause serious side effects.

I am 65 and have suffered from chronic migraine for 16 years. I have been on various medications, the best was Flunarizine, which was wonderful for a year and then stopped working. The most recent was Propranolol, which did nothing even at 240mgs daily. However when I came off it, I was headache free for 3 weeks, which is most unusual! I tried Topiramate, before thatbut after a week at the highest dose, became very nauseous, which my neurologist said couldn’t be due to the drug as I was OK for a week. The nausea persisted, on and off evn when I came off it, and I had GI tests done, all negative. At the moment, I am back to taking Sumatriptan every 2-3 days, and have lived in fear of developing MOH, until I read your blog. Pregabalin has been suggested as a next step, but I’m worried about side effects. I’m wondering about Botox, though it doesn’t seem to have a very good press here in the UK. Thank you for your interesting blog.

Hi. It is my 1st time ever writing on a board 🙂
I have been suffering from migraines since I was 10 years of age. But never more than 2-3 per year until I turned 41. All I needed during this period was some aspirin with codeine and it would do the trick.
For the last 8 years, I am now 49, my migraines progressed gradually from 2-3 a month to 10-12 a month. I have been living in Taiwan now for 5 years…Very humid climate and polluted as well. Oh and I have fybromyalgia…
I have taken topamax, inderal, lyrica, to no avail. Made life style changes as well. Manage my stress. Botox doesn’t seem to help so much. I have tried magnesium 400mg, melatonin.
I end up once every 2 months at the emergency for a shot of dexamethasone…I know most of my intractable migraines are linked to my period. So I tried an oestrogen patch. It hasn’t helped at all. I am presently taking cymbalta, 60mg, elavil 50 mg, rivotril .5 mg to help with sleep and the anxiety I feel when I feel a migraine coming on. My mood is better, I have to say but the migraines remain the same in frequency and intensity. Temple headaches, right and left, frontal headache, “sinus” headache etc…
My neurologist here in Taiwan says triptans: no more than 2 a week…Obviously reading your article helps rationalizing what I end up doing anyway: zomig spray or pill, amerge, maxalt as
needed. Dr Mauskop, is there anything else I can do or try that you would recommend?I should be moving and heading back to Canada where the weather I hope will have lesser of an impact on the migraines. Thank you for your article. Really.

Thank you for sharing your experience. Yes, insufficient sleep and irregular sleep patterns are well-known triggers of migraines. You could try taking melatonin before going to sleep, but it is not a proven treatment. You don’t need to get sumatriptan from an online pharmacy – go to GoodRx.com and you can find sumatriptan, 100 mg at one of your local pharmacies for $1.50 a tablet.

Dr. Mauskop- I am a physician who has chronic near daily migraine headaches. I have seen 3 different neurologists over the last 15 years. I have tried a variety of prophylactic medications: Inderal, verapamil, Topomax, Neurotin and Botox. I have tried Magnesium, melatonin, and lifestyle changes. I am an ED physician working swing shifts and often wondered if the irregular sleep patterns were the culprit but for the last year have worked only a 10 am to 10 pm shift and there has been no change in the frequency of headaches. The only medication that has ever helped is sumatriptan which I often take nearly daily. I occasionally take an NSAID or a Fioricet (once very few months) if the headache is particularly severe. All three of the neurologists I have seen have warned against daily use of sumatriptan, primarily voicing concern about about rebound headaches. I have searched for scientific articles regarding long term and/or daily use of sumatriptan and have found a paucity of research in this area. I appreciate reading this perspective regarding chronic use. It confirms what I have intuitively thought about my use of sumatriptan. I have experienced no obvious long term ill effects. In fact, I have managed to work full time with no missed days of work because of a headache for the last 15 years.
Finally, in reference to insurance companies and obtaining approval for more than 9-18 tablets a month, I gave up that fight a long time ago. My FMD writes an RX for 36 tablets per month that I obtain from an online pharmacy for less than $60 a month.
If you know of any research in this area, I would appreciate those references.
Thanks again for this article.
Dr. Janet

I always recommend starting with aerobic exercise, biofeedback, magnesium, and other supplements – you can read about all these on our site. You are saying that you are reluctant to start prophylactic drugs, but buspirone is also a prophylactic drug. Several other anxiety medications, such as nortriptyline and Cymbalta also help prevent migraines. All of them have more side effects than Botox, which is also more effective for the prevention of migraines than drugs.

Dr.Mauskop. Thank You for this blog. Very informative. I am 44 and have been taking sumatriptan since it came out in 90?s. Had migraines 2 to 3 Times’ a week then. Now i am migraine free a few weeks only to get an attack every day for the next couple of weeks. Takes one 50 mg tab. to abort. Its a godsend.
Last couple of years i developed anxiety problems. Tried buspirone 5mg twice a day for a couple of months. Didnt do a miracle for My anxiety but almost stopped My migraines. In a course of 4 months i had about 3 mild migraines. It stopped working after 4 months and i discontinued buspirone. Now 3 months later My daily migraines are back and i want to try buspirone Again.
Any of your thoughts would be greatly appreciated.
P.s. Too reluctant to start preventitive meds with their scary side effect profile

Cefaly does not seem to be very effective for severe migraines, but it is safe to try. It is similar to TENS, which can be used in place of Cefaly since it is much cheaper. TENS is usually used by physical therapists and you also need a prescription for it, like with Cefaly. It may be also worth trying Botox one more time.

Thank you very much for the valuable information in your blog. I have almost daily migraines since I started menopause, and have tried just about everything there is. My first botox injections lasted 5 weeks (5 weeks of heaven – I remember what my life was life pre-migraine) but the second round didn’t do a thing – in fact, they seem worse. I wonder what you think of Cefaly? My neurologist had never heard of it and made jokes about it like it was voodoo science (an interesting attitude which revealed ignorance and insensitivity). I pointed out that it was recently FDA approved and it’s been used extensively in Canada and Europe. Do you think I can use it before the botox wears off? Meanwhile I’m going to try the daily 50 mg of sumatriptan.

Unfortunately, I cannot give specific advice without seeing her first. However, NSAIDs before exercise and Botox injections are reasonable approaches which you should discuss with her doctor. In general, I do not find verapamil very effective for migraine, while it is great for cluster headaches. The average dose of nortriptyline for headaches and pain is between 25 and 75 mg, so a higher dose might be more effective. Again, talk to her doctor.

Dr. Mauskop, I have a 13 yr daughter who has a chronic migraine-intermittent April/May 2014, severe for 3 wks June 2014, knocked down to 2/10 with 10mg nortriptyline since then. Problem is my daughter is a high level athlete and exertion makes the migraine worse (3-4/10) which affects her athletic performance. Propranolol gave her a few 0/10 ratings over a few days but she could not tolerate the exercise intolerance. She I is now on 20mg nortriptyline and verapamil 120mg/day but still unchanged at 1-2/10 and 3/10 ratings with higher exertion. How do we get those her to 0/10? Her neurologist does not want her to use NSAIDS or triptans unless she gets a severe migraine brewing out of fear of eventual MOH rebound. Would it be wrong to use a triptan to try and knock her symptoms to 0? Can indomethacin or advil be used pre-exercise? Is it time for botox or should we increase the verapamil? Thanks.

Yes, you need to see a neurologist, get an MRI scan and some blood tests, including vitamin B12 level.

It is reassuring to hear that a doctor who has prescribed daily triptans for many patients over a long period is still confident in their long term safety. I am 46 and have suffered migraines since my teenage years. and never had any relief despite trying everything on the list until triptans, which are very effective for me. I have been taking Naramig daily (often twice daily a few days for a few days a month) for a number of years now, and this is the only thing that gives me a normal life. However, for the last year or so, I have become very concerned about my memory and brain functioning — my symptom is that I have trouble remembering stuff; it feels as though my brain is waaaay slower to retrieve memories, and words (I’m an academic, so I have to lecture a lot, so I would notice this) — my brain just finds the word it needs is not there, as with a person’s name, or a place, or the name of a university, or a movie, and I have to wait for it to come – and often have to try to step by step find the word by working through a number of associated memories to remind myself. Eventually I get there, or look it up, and then I do remember it. I worry that the long term daily years over a number of years might be contributing to this — have any of your patients on long term daily triptan use mentioned such a symptom? Can you think of a medical explanation given how triptans work for this side effect? Or should I be getting myself some MRIs to see if something more serious is going on? I know such descriptions may be part of the normal aging process, but I have tried to document some of these episodes and they do not seem like normal aging for someone my age.

Hi Dr.Mauskop. Thank You for this blog. Very informative. I am 44 and have been taking sumatriptan since it came out in 90’s. Had migraines 2 to 3 Times’ a week then. Now i am migraine free a few weeks only to get an attack every day for the next couple of weeks. Takes one 50 mg tab. to abort. Its a godsend.
Last couple of years i developed anxiety problems. Tried buspirone 5mg twice a day for a couple of months. Didnt do a miracle for My anxiety but almost stopped My migraines. In a course of 4 months i had about 3 mild migraines. It stopped working after 4 months and i discontinued buspirone. Now 3 months later My daily migraines are back and i want to try buspirone Again.
Any of your thoughts would be greatly appreciated.
P.s. Too reluctant to start preventitive meds with their scary side effect profile

Dr. Mauskop, thanks for your response and your opinion about the surgeries. The problem with Sumitriptan is that I can’t get my neuro to prescribe enough for daily use. I’m willing to pay some out-of-pocket expense if he would only prescribe it. I do appreciate the information about GoodRx.com, and I’ll check that out! I have tried topiramate which made me so sluggish I couldn’t function. I will ask my doc about beta blockers and ACE receptor blockers. The Botox was done in April, so it’s a little over 3 months. I may try that route again. I do exercise regularly and have for 15 years. I take magnesium and some other supplements (not sure which others you refer to). I haven’t tried biofeedback, but I’ll check into that. Again, I appreciate your help. 🙂

Frieda, I am sorry that your neurologist is giving you drugs such as Midrin and Fioricet, which are much more likely to cause rebound headaches than sumatriptan and on top of that they are potentially addictive. But most importantly, they have never been proven to help migraines and they usually do not. Lamictal and verapamil also are not very effective for the prevention of migraines. Of seizure medications, it is gabapentin, topiramate and divalproex that work. But all of them can have more side effects than sumatriptan. Among the blood pressure medications, it is beta blockers (atenolol and others) and ACE receptor blockers (losartan) that can help. Botox is worth trying twice in a row – three months apart. If your first Botox treatment was more than 3 months ago yo would need to try two back to back. Omega procedure, decompression and other surgeries are unproven, can cause serious side effects and probably do not work better than placebo. Surgery is irreversible and can make the pain worse. It is much safer to take sumatriptan every day. Sumatriptan has become very inexpensive – you can buy 30 tablets for $45. Check out GoodRx.com website for the cheapest prices (and coupons) in your area. Of course, you should also try non-drug approaches, such as regular aerobic exercise, biofeedback, magnesium, and other supplements.

Dr. Mauskop, THANKS VERY MUCH for this blog! I am suffering daily (mostly nightly) migraines and am also a victim of the “too much triptan” thinking. Sumitriptan is the ONLY medication I’ve taken so far that gets rid of a migraine. My neurologist will prescribe only 7 (100 mg.) every 21 days. I cut them in half out of panic of not having enough, but many times it takes 100 mg. to abort the migraine. I also take Lamictal (100 mg.) twice a day as a preventive. My neuro gave me Midrin and Fioricet for taking in between Sumitriptan, but all those do is make me sleepy and dizzy. I tried Botox once with no effect. Should I try it again? Tried Verapamil but it makes me too nauseous. Last week I also tried the temporary Omega Procedure, which works for so many people, but it didn’t work for me. My migraines are 95% in my middle forehead/nasal area, with an occasional one in my right neck/head area. I am thinking of checking into nerve decompression surgery. What is your opinion of that procedure? I’m feeling kinda desperate….thanks.

Frova or another triptan taken ahead of the cluster attack might help. Taking 400 mg of magnesium daily can also help prevent attacks or at least reduce pain intensity. Cluster headaches also respond to preventive medications – here is a brief summary.

I am male 49 and have suffered from cluster headaches for over 20 yrs, usually every 2 years free, then have 12 to 20 week period. I am 4 weeks into new cluster and am taking 1 to 2 100mg imigran radis tablets every 24hrs cut up into thirds. I am in the process of also getting oxygen. I am considering trying Frovatriptin as am getting an attack every hour when going to bad some attacks severe some not, but waking me up. I also find in the daytime one hour after eating lunch or tea I get very heavy shadows, any idea why?. Do you have any thoughts on Frovatripan for cluster headaches, I am also very pleased to read your acknowledgement about triptans not having rebound effects as this was told to me years ago by my neurologist, however many sufferers are adamant daily use causes rebounds.

It is unfortunate that doctors keep telling patients about the long-term risks of triptans when there is no evidence of such risks. No articles have ever been published documenting heart complications due to long-term use of triptans, even in patients who take them daily. Triptans have been in use for over 20 years – long enough to detect heart problems or other long-term side effects. It is unpleasant and difficult to confront your doctor, but I would suggest mentioning this blog and asking if they know of any scientific articles that mention long-term problems with triptans. You may want to consider trying preventive medications such as gabapentin and other, although the best preventive option is Botox injections.

I have had migraine headaches for over 20 years. I have eight to ten migraines a month; some lasting two to three days, but then it might be a week before the next migraine attack, so I don’t have to treat them daily. Ten years ago, I began treatment with Maxalt, and it was a life changer. No other medication eliminates the pain, and over ten years I have never experienced any of the possible side effects associated with triptans. The migraine is completely gone within an hour or so, and I am able to function normally. Initially insurance would only allow 6 pills per month, but slowly over the years the formulary was updated to allow 24 pills per month. However, GP would never prescribe more than 8 pills per month, because triptans ‘can be dangerous’, and cause stroke or heart problems. I am a healthy, 62 year old woman, with no medical conditons. BP and weight in normal range, cholesterol level is low; no heart or thyroid problems. The only medication I take is Advil for occasional aches & pains, vitamins and the Rizatriptan for migraines. GP now refuses refill of triptan med, and sent me to a neurologist who also has concerns regarding use of triptan meds in patients over 60 due to the constriction of arteries in the heart. He wants to try gabapentin and homeopathic preventatives. Is there research available regarding the risk long term use of triptan meds in healthy patients over 60? It is very frustrating to have to suffer from migrain attacks once again while waiting to see if the preventative treatment meds work.

You can try convincing your GP by pointing out that you went for two weeks without medications and your headaches did not improve, which proves that these are not “rebound” or “medication overuse headaches”. You should also mention that some of these drugs (triptans) are sold without a doctor’s prescription in UK and other European countries, which proves their safety. In fact, if you live in a country where sumatriptan or another triptan is sold without a prescription, you could try taking it instead of Zomig, however do consult your GP first since I cannot give specific advice to anyone without having them as my patients. You may also be able to appeal to someone in your country’s health care bureaucracy.

I have cluster headaches which predominently start in the early morning, frequently making communting to work very difficult. If I have an important event (such as my daughter’s wedding last September) I have been taking Zomig the night before and discovered that this averts the usual pattern of waking with a bad head.
My question is how do I get my GP to agree to prescribing this quantity. Certainly most of the health professionals I am involved with refer to this kind of treatment as increasing these attacks; to the point that one of the GP’s at our surgery took me off all my medication for 2 weeks which was just hell on earth. I don’t have another appointment with my consultant for another year, as I have found him less than agreeable to any of my suggestions regarding my treatment it is highly unlikely that he will consent to this.
Kind regards
Mandy

Yes, there is a connection between serotonin and migraines and depression. However, the details are very complicated since there are many different serotonin receptors in the brain and throughout the body and the serotonin molecule can cause a wide variety of effects, depending on the type of receptor and its location. Drugs like Prozac (fluoxetine) are called selective serotonin reuptake ihnibitors, increase serotonin levels, but they do not help migraines. Antidepressants that affect serotonin and epinephrine do prevent migraines and relieve other pains. Triptans, such as Imitrex (sumatriptan) work on two specific serotoning receptor types and they do relieve migraines very well.
If you have depression you are twice as likely to develop migraines, while if you first have migraines, you are twice as likely to become depressed or develop anxiety. This suggests that serotonin is involved in both migraines and depression, but it is most likely that it is not just serotonin that plays a role.

About 10 years ago I started waking up with morning headaches which turn into migraines typically within the hour. Sometimes a startled awakening will cause pounding, and then an immediate migraine follows. They typically coincide with neck shoulder pain, eye blurriness, and nasal stuffiness. Within a month of when these headaches began, I was prescribed imitrex. It has been a godsend. Through my own trial, I have found that when I am having a spell of these headache mornings (which typically last 3-4 days) I can take a half dose (50mg) before bed, and abort the whole morning headache. Amazingly it also totally relieves any shoulder/neck pain, and makes my sinus drain. And on top of that it puts me in a very calm and at peace state of mind (not a drugged feeling, just a calm normal state). I am able to make decisions and get things accomplished. I know that imitrex has some effect on serotonin. My question is, since I am so relieved of pain, and cloudy thinking when I take imitrex, is it possible that my headaches are actually caused by abnormal serotonin levels and or possibly depression? Thanking you ahead for your thoughts.

25 mg of Imitrex is a small dose since most people need 100 mg to abort a migraine. However, if it does cause chest tightness, it is definitely worth trying other triptans since they may not do it. The chest tightness though is usually mild and doesn’t last more than 10 – 15 minutes. As far as propranolol (and probably not propopholol) can also cause chest tightness that persists, especially in those with a history of asthma. The usual dose of propranolol (Inderal) for migraines is at least 60 mg and as high as 160 and even higher. There are many other good prophylactic drugs (and supplements) to try besides propranolol, as well as Botox.

Dr. Mauskop, I have been a headache sufferer for over ten years. Just recently, I let down my guard and decided to turn to pharmaceuticals for help (the 600 mg of ibuprofen was not cutting it). I was prescribed Imetrix 25mg and propopholol 20 mg x2 daily. I have now taken Imetrex three days in a row. It completely aborted my headache (which I thought was a phenomenal), I now have a tight chest. I feel as though I have been coughing steadily for days and I have not. Would another triptan have the same side effect? I appreciate any help you can be.

I’ve had migraines for the last 36 years and have proved to my doctor that I don’t have Zomig overuse headaches by stopping them for 2 months. My migraines did not improve or become less frequent. I’m told I can take up to 10 Zomig per month without having medication overuse problems but I currently average 14 migraines a month and continue to take Zomig – sometimes for 4 days in a row. I honestly don’t know what I would do without it – it’s life saving! Works every time with no side effects. Thank you Dr. Mauskop for voicing your opinions. Just wish Astra Zeneca (who manufacture Zomig) would carry out trials and confirm that Zomig can be used frequently!

You can ask your neurologist to write a letter and if her or she is reluctant to do it, refer them to this blog post. You can also find generic sumatriptan for as little as $1.50 a pill; at a local pharmacy by going to GoodRx.com.

I am a chronic migraine sufferer who has had them since 5-6 years old. I am presently 75. I wake up with a migraine most early mornings and take an imitrex which allows me to have a headache free day. I am now in a war with my new drug provider who refuses to fund more than 18 tablets a month because “it is dangerous to take more than that number a month. I am only allowed 4 headaches a month. Does anyone have any ideas for data that I can include in my appeal that would support my case for atleast 35 a month? Thank you.

One possible explanation for why there is no downregulation of receptors with daily triptan intake is their very short half life. The three leading triptans, sumatriptan (Imitrex), rizatriptan (Maxalt), and zolmitriptan (Zomig) have a half-life of 2-3 hours, which may not be long enough to downregulate the receptors. Naratriptan (Amerge), which has a half life of 5-8 hours and frovatriptan (Frova) with a 26 hour half life, at least theoretically, should be more likely to cause downregulation, but there are no reports indicating that they are more likely to do that.

Another possibility is that triptans do not downregulate serotonin receptors at all, which is the case with SSRIs, such as fluoxetine (although they are not agonists). This is why SSRIs rarely cause withdrawal symptoms. Here is a good review of molecular pharmacology of SSRIs.

Most agonist drugs tend to cause down-regulation of receptors and thus worsening of symptoms upon discontinuation… do you have any pharmacological explanation as to why this doesn’t seem to be the case with triptans?

I am not able to find any studies on the topic…

Cheers and thanks for the article 🙂

Ive been stuck for 26 years taking all tylenol containing pain killers from Fiorinal to Morphine. I also have been on Imitrex since around 20 years ago as well. when they 1st came out in an inject-able pen. I also have been through the blood pressure meds and all that. ive seen 5 neurologists. recently got Botox.. Nothing helps. If i go off the pain killers I nearly die. the pain gets non stop and I just wanna kill myself. for some reason klonopin helps alot but its short term help as taking these 2 to 3 times a day makes them not effective anymore. So when I do have a severe migraine, i take 3 mg’s and it helps alot. I HATE going to the ER. I went once and walked out without pain and i was given Diaudid. They have never given it to me again. and I always spend 3+ hours for them to put benadryl in a IV and let me lay there with no relief at all. While making someone drive me home for nothing. I’ve been stuck for 20+ years with nothing.. Lifes been ruined by these things.

Yes, if you mix headache medicines that contain caffeine they definitely can cause rebound. Zomig alone is highly unlikely. If you were off both headache pills and Zomig for 8 weeks and headaches did not improve, then neither was causing rebound. Ask your doctor about getting either preventive medications (gabapentin, amitriptyline, and other) or Botox injections.

Have been off all meds for 8 weeks and it was living hell. Now 4 weeks after Im back to daily migraines. I did the mistake of mixing headache pills with zomig. Zomig helps better and Im thinking if its safer just to continue with only zomig. So confused by all the doctors who say that tritans cause rebound. Have any of you had rebound from only taking triptans. Or have you all taken both headache pills and triptans?

One more thing I wanted to mention. Dr. Robbins blog today, 4/10/13, states that triptans cause MOH so there is still controversy regarding this. Of course Dr. Robbins does not write the material he posts and much of the info in his blog is out of date. I was at Dr. Saper’s inpatient clinic in Michigan in 2004 and at that time they didn’t offer triptans at all. I don’t know what they do now.

I have also seen a few cluster headache sufferers whose attacks seemed to become more frequent because of Imitrex (sumatriptan or Imigran in Europe). One possible strategy is a short course of steroids, such as prednisone, starting with about 80 mg and reducing the dose by 10 mg every day. Anothe option is to try preventive drugs such as verapamil. Although, you are saying that you’ve been “effectively taking Imigran for about 14 years for migraines (you meant clusters) which occur for 4-6 weeks every 12-18 months”, so how did all the other cluster attacks stop if at the end you had to take more and more Imigran?

As with many sufferers of cluster headaches good medical advice is hard to find. I have been effectively taking Imigran for about 14 years for migraines which occur for 4-6 weeks every 12-18months. However, I am convinced that towards the end of the headache period, it is actually the Imigran which is causing the incidences. I am currently at 3-4 attacks per day, taking 50mg each time. I can push this out to about every 8 hours if I time the use of Brufen before an expected attack. I want to try to stop taking Imigran, but as every sufferer knows, the onset of an attack is so acute that the only choice is to take a tablet! I need advice on how I can stop taking the Imigran and get back to a normal 12 months before the next episode

One of the most common long-term side effects of Topamax (topiramate) is kidney stones, which occur in 20% of patients.

Do we know of any long term side effect from taking topamax?

In 2011 I appealed to my insurance company to get more than 9 Treximets a month and they agreed. In 2012 they denied it. My doctor and I appealed TWICE and both times we were rejected. I think my doctor actually talked to them on the phone more than twice. I take a triptan 3-5 times a week.

hi,i have been taking sumatriptan for about 25 years,im now 50,my headaches have been coming daily and im having to take 1 a day,i always got headaches through my menstal cycle but now i am premenopausal they have increased,i wait to see if my headache will go first with my normal paracetamol and aspirin,if it doesn’t then i take sumatritan,i am only prescribed 12 a month but have saved them up from my other prescriptions,they have been a god send for me as i used to stay in bed for 3 days a week,i am pleased to hear that they are safe and my life is better since taking these,i had tried other tablets midrid,beta blockers ect to no avail,i really don’t know where i would be today if it wasn’t for the sumatritan.

I am pleased to learn that Zomig does not cause rebound headache. Anxiety has gone! Thank you.

I am thrilled to learn that Zomig does not cause rebound headaches. Guilt has gone. Thank you.

There is no scientific reason for this limit, but it is based on the fact that the large clinical trials that are required by the FDA were done on patients who had only 2 to 8 migraine attacks each month (the exact number of attacks varied for different triptans). Pharmaceutical companies that make triptans never conducted studies on patients with more frequent migraine attacks and did not show to the FDA that taking these drugs more frequently is safe. However, these drugs have been on the market now for 20 years and have shown remarkable safety. In Europe, some triptans are sold without a doctor’s prescription. Body aches, jaw, or chest pressure is not uncommon after taking a triptan and it usually lasts 10-15 minutes and does not indicate a serious problem.

Botox is worth looking into since it is proven to relieve chronic migraines, however rhizotomy is a much more invasive procedure with unproven efficacy and possible serious side effects. Increased risk of stroke has been observed only in patients who have migraines with aura and even in those patients strokes are very rare, unless there are other risk factors. Some of those risk factors are smoking, high blood pressure, diabetes, high cholesterol and other. There is no age limit for the use of triptans. My oldest patient taking triptans (sumatriptan) was 85 years old, who was in good health and had no risk factors for coronary artery disease (CAD) except for her age.

why do they say only take it 2 times a week and why does it make my body hurt for a few minutes after taking

Hi, Dr. Mauskop. I suffered from menstrual headaches for years, only realizing they were migraines when my son was diagnosed with migraines around age 14. He was prescribed Zomig which worked well for him. His headaches were rare, unlike mine, so out of desperation during a particularly bad episode, I tried his Zomig. Yes, I know. No lectures, please. It turned out to be a miracle cure for me. I am now postmenopausal but am getting my migraines almost daily. The only thing that helps is Zomig. I have tried various prophalactyic treatments to no avail. I have not tried Botox but am going to look into that since I suspect some of my problems tend to be coming from arthritis in my neck. I am scheduled for a rhizotomy at the end of January. My concerns are as follows: I’ve been told that migraine sufferers are at increased risk for stroke. If tryptans can keep them at bay, could that then decrease my risk for stroke? What exactly is the risk to the heart? Eventually, most people end up with some level of CAD. At what point do you say to stop the tryptans? Since I don’t see my headaches going away without their use, what happens then? Thanks so much for this blog. It has been very helpful.

Unfortunately, I cannot tell you if you should or should not be concerned since I don’t know enough about you. Do come see me the next time you travel to NYC and then we will able to discuss your specific situation.

Thanx for your quick response. I’ve been taking 50 mg. of imitrex( or generic Triptan) for a number of years almost daily. I have no side effects, no need of dosage increase, in short, a perfect drug. In a recent check up however, my doctor said that ” imitrex is not meant to be taken everyday”when I asked why he said that he wasn’t sure an refered me to a neurologist . That’s when i did some research and found you. I was very impressed with your background and straight forward approach. I am 71 years old, in excellent health ,exercise daily eat well etc. I do travel and I’m out of town right now. My question is whether or not I should be concerned with the current situation , try other treatments. Come to see you when I’m back or simply enjoy the fact that someone of your credentials and experience is not alarmed by this way of dealing with my headaches . Whether migraines or not, Triptan is the only medication that works for me . Thanks again,Ron.

Yes, there is a good chance that your doctor’s request for more than 8 tablets of Imitrex may be honored. If not, you can start an appeal process and if you are persistent enough and don’t take no for an answer you will get a large amount approved. You can also ask for 100 mg tablets and you will probably get 8 of those, which you can cut in half, so you will have 16 doses. Generic Imitrex – sumatriptan is getting cheaper every year, so you may be able to afford to buy a few additional tablets every month.

I take imitrex 50 mg. daily , it’s a life saver for me. How do I get a prescription for more than eight a month? Will my insurance provider cover more on a doctor’s request?

Yes, it is worth asking your doctor to appeal the denial. You can also start calling and writing to everyone up to the president of your insurer and your state’s health insurance commissioner.

Dr., our family doctor has given permission for my husband, 69, the migraine sufferer, to have 6 boxes of 27 tabs; insurance covers it, but the mail order pharmacists will not allow it any more. My husband is a daily sufferer and has been hospitalized by a neurologist in the past to try to get him off the rebound migraines. To no avail. He ended up back at the same spot.

How do we convince the pharmacy (mail order) that he needs it. Our life is consumed over this issue. Plans cannot be made very far in advance because he may be without sumatriptan. Can our doctor fight for us in this matter? Or is it a waste of her valuable time? Thank you!

Hi Dr. Mauskop ! I just now stumbled upon your site and I’m really happy that I did.I am a long time migraine sufferer and started getting them at 17yrs old.I’m now 39.the only way I can describe the excrutiating pain to people is to tell them that it’s literally like being tortured for about 24 to 36 hours in a row (that’s about how long mine last).I get them several times a week and there have been many times that I have wanted to end my life.But that was before I started taking daily triptans.I can safely say that before giving me this option, my doctor had really tried everything else and for quite a few years.What a MIRACLE it has been for me.One day I broke down crying in his office, begging him to just please STOP THE PAIN !!!!! that’s when he gave me Imitrex, which has given me back a huge chunk of my life.I take about 100 to 150 mg a day (sometimes even half of one pill will do the trick).I even hold down an almost full time job now (4 days a week).I live a pretty normal life now.Thank you so much for all the information, wish more doctors were like you.

I have read that migraines are now neuro, not vascular. Still, triptans work for me, which my allergist insists means I have migraines, not sinus headache. I also have migraines, only since menopause, so I know the difference. A triptan before bed means no middle of the night pain, and a subsequent good day. I’m gratified to read that’s okay, but I’m going broke. I will go the the neuro routine to satisfy everyone it’s not a tumor or something but I will not do the preventive list because those drugs scare me more than triptans and as I say, I’m pretty sure I have bad sinuses causing my daily headaches….I only get them prone, for example…and I get a respite out of allergy season. So how do triptans work if its not about vascular problems? And when do we get cheap triptans?

Five Tylenol with codeine daily can definitely make your headaches worse, while triptans are much less likely to do that. You should get off your medications under your doctor’s guidance by first gradually stopping codeine – reduce it by one tablet every three to five days, while continuing your triptans as needed. Having another round or two of Botox injections first may make it easier getting off these drugs. It is very unlikely that Botox made your arthritis worse – it might have been a coincidence. In order to avoid neck muscle weakness ask your doctor to inject less Botox into your neck muscles.

Your are right in that triptans are not indicated for the prevention of migraine headaches and are not intended for daily use. However, if they work they are much less likely to cause rebound headaches than pain killers such as codeine. I do have a small number of patients taking daily triptans who are doing very well, but I always try to use other preventive measures, such as drugs that you’ve already tried, various supplements, and Botox injections. You may have to try several triptans before you find one that works well and is not causing any side effects.

I have been suffering with dizziness for over 2 yrs 8 mths and i was told it was labyrinthitis, then this march i was getting pounding headaches and just not eased. Saw a Neauro consultant last wk and told i suffer with Migraine with dizziness, thats Migraine Assiated Vertigo. I have episodes where im vertually symptom free theh it all flares up again. I have been on loads off meds for this, including Topamax, Nort, Prop and many more. My consultant wants me to start Triptan but confused as i get pounding headaches every single day, normally evening time its at its worst. I was told to come off all pain relief, i was taking codeine as its rebounding on my headaches, now not on nothing till this wk till i see my gp again. I thould with these Triptans u cant take every day, i thought there suppose to treat the headache once started and not prevent them ! Can i take other prevention meds to with these and what the beds Triptan to take, dont want all the side affects as i still work full time for the NHS. Thankyou

I’ve been suffering with migraines for about 4 years (I’d has some episodes earlier in life but they came with menopause. The last four months have been particularly awful and I’ve ended up taking a triptan (sometimes 1/2 or sometimes one or two) every day. I’ve also upped my pain medications (Tylenol 3) to about 5 per day in the last six weeks, just to be functional. I am on Nortriptaline. I tried Botox. It made my psoriatic arthritis flare up but did seem to get rid of the headaches for three months once I got over the horror of having a floppy neck. I was on Prednisone for the arthritis for 5 months and was also at the same time on a very strict diet; during this time I had virtually no headaches. Like others here, I am freaked out about my daily triptan use. Also, I obviously need to get off the Tylenol 3. What sort of taper would you advise? Is it possible to taper off Triptans? I have stopped them once cold turkey after taking them for a month. It was pretty awful, but I stopped getting quite as many headaches. Alas, the stress produced a bad arthritis flare. Any counsel would be much appreciated.

The official limits on how many triptan tablets or injections can be taken within 24 hours are not based on scientific studies. The original efficacy studies set an arbitrary limit and it is extremely likely that taking 3 instead of 2 doses is perfectly safe. In fact, Maxalt (rizatriptan) is officially indicated to be taken up to three times (30 mg) within 24 hours and when Imitrex (sumatriptan) was first released it was also approved for up to three times a day (300 mg). Discuss with your doctor if you could take 3 tablets of Axert (almotriptan) in 24 hours for your cluster headaches. Many of my cluster patients face the same problem with injections of Imitrex. The official limit is two 6 mg injections within 24 hours, but many take it 3 times or more when the pain is extremely severe and they see no other choice. Another problem is that insurance will often pay for only a few tablets or injections. Sometimes I prescribe vials of Imitrex and syringes, rather than self-injected cartridges and this way some patients can take half a vial, 3 mg and even under official rules could take 4 of such injection in 24 hours. In addition, injecting with a syringe and needle is often less painful than when using auto-injectors.

I have cluster headaches and am in cycle right now. Axert works very well for me, but I was wondering if there is anything that can be used after the daily limit had been hit?

I’ve take two already and have another ten hours to go before the twenty-four hours is up. Is there anything else I can do or take if another headache comes before then?

Since the last Axert I’ve taken, I’ve had another two headaches. I don’t usually get them during the day, but I am getting nervous that another may come before tonight again.

A follow up to my post back in April: still struggling to get rid of the Babesia, the migraines/headaches still come back with a vengeance every few hours, and I’m still on daily triptans. I hate the ball and chain I have with triptans, but I have tried Botox, neurontin, topomax, prednisone and elavil, and a bazillion other combinations over the last 10 years that unfortunately did not work. I can reduce the pain slightly with massage, reiki, meditation, biodfeedback, and of course I watch my diet to reduce headeache (vegetarian, no coffee, not too much sugar, salt, or chocolate, no MSG, etc.), but to date the only thing that rids me of pounding migraines is sumatritpan (usually 50 mg can do the trick).

Tests show my heart is fine, my BP low, my pulse healthy. My Lyme MD, Dr. Yang – who I respect very much and is constantly attending conferences and updating her knowledge – says that it is apparent the fluid is not flowing out of my head thanks to the babesia and inflammation (that is MY unscientific paraphrasing), and it doesn’t wholly surprise her that the triptans work when other things don’t. Problem is most of the babesia treatments make my head worse (supposedly due to the inflammation from the die-off), so treatment is painfully, terribly slow, and may not be aggressive enough.

And so we keep trying combinations of pharmaceuticals and herbal remedies, knowing chronic babesia is a tough nut to crack. No luck yet, but thought you’d be interested as my case seems to be rather unique in the world of mainstream information, and it would have been nice to have had an MD who had a clue about Babesiosis (and Lyme testing in general, I recommend IgenX lab) 15 years ago, could have saved me many years of suffering and tens of thousands of $.

Thanks for your reply. I’m also on topamax, inderal and get Botox every 3 months.

There is no evidence that tramadol or ibuprofen cause MOH, however it is always best to try to find a preventive therapy.

What about when a triptan alone is not effective? I have daily headaches, treat 3-5 days. I do just what you describe – wait until the headache is so severe that I can’t take it anymore and not sooner b/c I don’t want to waste a dose. But, if I take just naratriptan 2.5mg or sumitripan 100mg that is not enough, so I also take tramadol 50mg and ibuprofen 600mg. Two out of three will not do it.
Does tramadol cause MOH headaches?

Occipital nerve block can be very effective, but you should also ask your doctor about verapamil (high dose – 240, then 480, 720 mg and even higher if there are no side effects). Botox is not approved for cluster headaches, but I have a few patients who responded well. For cluster headaches you need less Botox than for chronic migraines, so it should be less expensive, but insurance may not cover it since Botox is only approved for chronic migraines.

I have been a cluster headaches sufferer for 20 years. I have tried everything from Lithium, Fiorinal, Sansert, Imitrex. The only thing that aborts my headaches are Zomig and 100 oxygen. I am in a cycle period right now and I’m averaging two zomig nasal sprays a day (5mg?) I am going for my first nerve block injection tomorrow hoping it will break the cycle

I also take triptans (sumatriptan)more or less daily. I am coming up for 50 and have taken this drug for years since it first came out. It was only by injection then though. My GP has always been very good about prescribing it for me, but a lot of other people struggled to get their GP to prescribe it until the cheaper generic version came out. I have 12 100 mg tablets in two weeks by prescription but we can now buy it in the chemist. It costs about £8 for two 50 mg tablets.

http://migraineresearchfoundation.org/completed-research.html#top-wholepage

It looks like some of these studies reach the conclusion that MOH can be caused by Triptans. YOur thoughts?

I read this post when you first published it. At that time I was doing fine with my insurance allowance of 9 tablets of sumatriptan (100 mg) per month. However, shortly after my migraines started coming more often. After trying various things, I got an approval for 72 tablets every 3 months. I don’t use all of them. When i feel a headache beginning, I take half a pill and most often within half an hour the headache is gone. It may come back later in the day and I will take another half a pill. I don’t exceed 2 pills a day.

I feel very good with this regimen as I am completely functional. Previously, there were days that I couldn’t get out of bed. I recently saw my neuro and he asked how often i have headaches. I didn’t really know but i estimated that I had taken 50 pills in the last 3 months. He thought 50 headaches in that period was a lot but I pointed out that sometimes I needed more than one pill to treat.

I agree that I do not have MOH as I suffered from that many years ago. I was prescribed stadol and other narcotics and it took many months after I quit taking them for the severe daily headaches to stop.

Now i have been asked to keep a headache diary. I suppose the purpose here is to evaluate how well my preventatives are working.

I am so glad I came across this information. I have suffered almost every day for the past 15 years with chronic migraine. I am now 45. I have been on about 15 different preventatives and had Botox in July, none have worked.

For the past month or so I have been taking Maxalt every day, and today I thought my Dr is going to go mad at me for this, so I haven’t taken one today and my head is agony. After reading this, I am going to take one.

I am seeng my neurologist in two days and I am going to show him this.

I spend so much time worrying about taking Maxalt or when my next migraines going to happen that my life is just rubbish.

Gill.

I meant taking Triptans up to 3 times WEEKLY

I have daily migraines, but also was diagnosed with undifferentiated connective tissue disease. Taking Triptans worsens my condition, as I have Raynaud’s and the Triptans exacerbate that condition, as it constricts the blood vessels. So, I only take Triptans three times a week, and then I take Vicodin to help with the migraine pain. My neurologist is fantastic and understanding, and I believe this is the best strategy for me. Another neurologist told me to stop taking the Vicodin, but I believe my quality of life would be much worse. I am able to lead a fairly normal life and am not in bed every day as I used to be. Do you think this strategy is a good one (i.e., Triptans up to 3 times daily and Vicodin as needed – one or two a day at most?) Am also on Neurontin daily. Have tried 8 other medications to help reduce the frequency of the migraines.

I find that Botox works for about 70% of my patients. What I mean by “works” is a range of responses from complete relief following the first treatment, which is rare, to very mild improvement that gets better with each subsequent treatment. Sometimes improvement after the first Botox treatment is so gradual that some patients realize that they were improved only after three months when headaches start to worsen. I also see patients who tell me that their are headaches still occur daily and that Botox did not help, but when they fill out the MIDAS disability questionnaire there is a significant drop in their disability. For some people Botox at first only improves relief they obtain from abortive medications, such as triptans (Imitrex – sumatriptan, Maxalt, etc). It is worth trying Botox at least twice before making a decision about how well it works. You should also know that it takes at least a week or two after Botox injections before any effect may appear.

Dear Dr. Mauskop,

My mother is a chronic migraine sufferer who is finding that daily Imetrex use is no longer effective. She is also taking preventative medication (anti-seizure) which doesn’t help. She will start Botox injections next week. I am wondering what your experience is with the success rate of this procedure and what we should expect.

Thank you in advance!

I am glad you found this information useful. You may want to ask your neurologist about getting Botox injections, which is the only FDA-approved, most effective, and safe treatment for chronic migraine. Botox may improve your quality of life beyond “acceptable”.

Dear Dr. Mauskop,

I am a pediatrician with chronic migraines and take 100-300 mg of Sumatriptan daily. I do so to be able to function, I have been tried on countless preventive medications most of which had significant side effects (I could not function as a doctor on either Topiramate or Valproic Acid for example.) I am very relieved to hear your views on daily sumatriptan as it is the one medication that allows me to have an acceptable quality of life. Thank you very much for your thoughtful comments.

Rebound from triptans does not exist, bu tit does from caffeine and narcotics (opioid) medications. It is extremely rare to need to take more and more of the triptans.

Also, per your earlier post:

‘Most of my colleagues in the headache field, even those who (erroneously) believe in rebound from triptans, admit that they have a few patients taking triptans daily. The largest study to date was conducted in France.’

Does this mean that rebound headaches do not actually exist? that would be a huge relief. My anxiety over the rebound effect is making everything worse.

I’ve tried the botox, topamax and gabapentin. Nothing helps but the triptans. I’m concerned I am having rebound headaches since they are now daily. The imitrex helps and I have no heart issues. If I stay on this course- and if they are indeed rebound- does this mean they’ll get worse and worse? that I’ll need 2 or 3 imitrex a day? If not, I’d rather stay on one a day then go through the withdrawal experiment to see if they are rebound headaches. I don’t think I could tolerate the pain.

Thankyou once again for your reply and advice. I discontinued Topamax at the beginning of the year as it ceased to provide any relief. My neurologist replaced it with Sibelium as he and his collegue, Peter Goadsby, have used it successfully for NDPH and migraine. I am still on 5mg, working up to 10mg in the next month or so. My psychiatrist suggested increasing amitriptyline to the therapeutic dose for depression i.e 150mg as the constant pain causes severe anxiety. I have since lowered the dose to 100mg as the side effects in conjunction with Sibelium were to severe. I am just praying that this next round of botox provides some relief.

Yes, a full dose of Botox might work better. If headaches persist, ask your neurologist about raising the dose of Topamax (I have some patients who take 400 mg or even higher, provided they have no side effects) and/or amitriptyline (after checking your amitriptyline blood level). If nothing helps, it is much safer to take a daily triptan than taking steroid medications and possibly even other daily medications, as long as you have a healthy heart.

Thankyou for your reply. I have had four rounds of botox previously, but never the current protocol of @ 31 injections of 155 units of botox which I have booked for this friday 3rd August. I have tried oral prednisolone starting on 60mg and then tapering, but it has no effect on my pain. 500mg a day of IV methylprednisolone over 3 days has always taken my pain back down to @
1-2/10 but I have had 5 courses in 10 months, and my neuro is very worried about what it is doing to my bones. It is so sad that the only thing that really helps is something that I can’t have.

I would suggest asking your doctor about taking a 10-day tapering course of methylprednisolone or another steroid in order to stop taking triptans to see if stopping them will improve your headaches. Another treatment that helps reduce medication intake is Botox injections.

My daily headache started after a viral infection in October 2009. I was diagnosed with NDPH in 2010 and then in the last year I started getting severe migraines, mostly menstrual related. In September 2011 I discovered triptans, in particular Amerge, and am now stuck using them daily. My migraines used to be only during my menstrual cycle, but now they are daily and my heads sensitivity to triggers has increased dramatically. Prior to September 2011 I never had these problems and I managed my NDPH extremely well with topamax and amitriptyline. I blame triptans for the state of my head today, but I just can’t get off the merry-go-round. The only infusion that helps my pain is methylprednisolone, but the serious long term side effects rule it out as an option.

The only way to know is to stop taking triptans for a couple of weeks to see if headaches improve, although it can be difficult because headaches often get worse before they get better. Some people can manage worsening due to withdrawal by taking a course of steroids and other medications, but some need to be admitted to the hospital to manage their withdrawal headaches. Another approach is to continue triptans and to start a preventive medicine such as gabapentin (Neurontin) or topiramate (Topamax) or to have Botox injections, if that hasn’t been tried yet. These preventive treatments may make it easier to stop the triptan.

I have headaches mostly every day… I used to have some days a month that were headache free but that is much rarer now. I usually take one triptan a day- two if it is severe. My question is how can you differentiate between a ‘rebound headache’ and just a migraine? If my HA frequency is up slightly does that indicate rebound? I don’t understand how to tell the difference. thank you!

If one Imitrex a day relieves the headaches over a long period of time there is no reason to worry about rebound. The only concern is if the person taking Imitrex (sumatriptan) or other triptans has heart disease. If someone has several risk factors for coronary artery disease, such as smoking, high cholesterol, diabetes, high blood pressure, strong family history, a nuclear exercise stress test should be done.

I am so happy I found this page. I have had headaches for years but for the last few years they have been daily. I am at my wit’s end- I have tried everything to prevent migraines- including botox- and still the only thing that seems to work is a triptan. I also try to not take one until it is severe and then end up taking one daily anyway. I’ve been panicked about rebound headaches and this page alleviates some of that anxiety. Should I be concerned that my headaches used to be about 3x a week but are daily now (and for the past few years?) They seem to be holding steady at daily and 1 imitrex a day usually does the trick. But I’m so worried about rebound that it makes everything worse.

You may want to try Botox, which was approved for migraines in the UK before it was approved in the US. Your national health service initially refused to pay for it but now they do. Botox is more effective and much safer than any drugs.

PS. I ought to mention that I have high cholesterol and do worry about having a stroke. My blood pressure is very good and my GP does not want to give me statins for high cholesterol because my liver shows signs of stress. Other than that I am on no other medication except migraine medication. I have naturally high cholesterol and however hard I try to get it down it does not work. I look forward to hearing Dr. Mauskop’s thoughts. I feel rather alone as I don’t personally know anybody who suffers as badly as I do. If I took a triptan every day would it be better than living like this? It seems nobody in England can come up with anything to help me. I have visted the London Migraine Clinic, seen neurologists, taken all kinds of medication but nothing works for me. I am pretty desperate.

I am really glad I stumbled on this site. I am a chronic migraine sufferer and was prescribed Zomig many years ago. As the years have been by I seem to have to take a Zomig every day or at least three times a week. I have been told by a neurologist that I must come off them but however hard I try I cannot manage as I am physically sick and become dehydrated without any medication. I cannot make the medical world understand that this is a dangerous situation for me to be in. Therefore, I am left with taking another triptan just to get me through the day. I spend at least 3 months of every year in bed as I try to hold out without taking a triptan and then become so ill I have to take it in the end. Sometimes I take a triptan as the very first sign of a migraine and it works much better but the more I take the more I need. It’s a viscous circle but I am rather relieved to learn that some people do take a triptan every day. Perhaps it is better to do this rather than spend so much time in bed and have a ruin life as I have. My life is a mess at the moment and I rarely have a good day.

I just stumbled on this article… I am from Central Europe and I am still shocked at how the headaches or migraine are treated here. I am a nutrition specialist and every time I hear from people that their doctors are giving them a lot of chemicals without any additional information, side effects or alternative treatment options I just disagree sadly.

Most of my colleagues in the headache field, even those who (erroneously) believe in rebound from triptans, admit that they have a few patients taking triptans daily. The largest study to date was conducted in France. Using National French Health Insurance System data the researchers looked at all triptans prescribed over a period of 3 months in a rural part of France with a population under 3 million. They found 8625 people who were prescribed a triptan at lest once. Of these, 165 were receiving 30 or more triptan tablets each month and another 866 were taking 15 to 29 tablets. The most important conclusion of their report was that they dd not find any relationship between the overuse of triptans and cardiac events.
One of the best ways to try to get off daily triptans or drugs that really cause rebound, such as Fioricet and Vicodin, is by using Botox injections. Intravenous infusion of magnesium can also help, especially if the patient has other signs of magnesium deficiency, such as cold extremities or feeling cold in general, muscle cramps in legs or feet, PMS, and other. Medication options include gabapentin (Neurontin) or topiramate (Topamax), two drugs that have been shown to relieve chronic migraine. Topamax has many more side effects than gabapentin. And, there is a long list of other prophylactic drugs that can be tried.

I have only managed to find one research article regarding effects of daily triptan on patients, looking mostly at heart health. http://www.headachedrugs.com/archives/daily_triptan_use.html
Not having access to full medical databases, I am wondering if there are others?

The article says ‘The patients were carefully screened for the presence of rebound headache. If the history was possibly consistent with rebound, the patient was withdrawn off of the triptan.” What criteria do they use to determine if daily users are rebounding or not?

Finally, I am always searching for new information on how to reduce triptans rebounds in case it is possible, just going cold turkey is simply impossible for me, I’ve tried many times. My last neuro wanted me to take prednisone with elavil. I told her I had tried them concurrently before – for months – to no avail. She wanted me to retry them anyway.

Other neuros recommend DHE, one even gave me injectables to take every day (on my own, with an anti-nausea). So far I have balked at the idea of at-home daily DHE injections. Are these the most current pharmaceutical strategies for reducing rebound (if it exists)? I am trying to decide if should I seek out yet another neurologist (#12) to discuss this, my hesitation is I don’t want to be subjected to the “you’ll die of a stroke soon” brick wall yet again.

My current MD is a (wonderful) Lyme disease specialist, but not a neurologist.

Thanks in advance, it is an extremely rare moment I get to ponder these questions with an informed person. Don’t worry, I am aware you aren’t going to be giving individual patient advice on my condition.

I want to clarify one point. Using triptans daily should not be the first or even the fifth approach to treating chronic migraine. We always start with elimination of triggers, magnesium, Botox, prophylactic drugs, and so on. Only if all else fails, we resort to daily triptans, mostly because of the cost. If they were much cheaper I would probably skip trying a few prophylactic drugs with most side effects. My estimate is that only about 2% of my patients end up needing a daily triptan.

Unfortunately, I see many patients whose doctors keep pushing on them unproven, toxic and addictive drugs, but will not allow taking a daily triptan, which is much safer, much more effective, and allow normal functioning.

This is quite an amazing blog coming from an MD. I am in my mid 40s and have suffered migraines since age 30. I have also – after all these years – been diagnosed by a specialist with Babesiosis, a tick-borne parasitic infection known to cause severe migraines.

I’m a wildlife biologist, however it took 15 years to be diagnosed with this. Sadly treatment is difficult and slow, because the treatment stimulates worse pain in my head, and the little buggers that live in your red blood cells are damned hard to get rid of.

But the reason I’m writing is because I spent many miserable years of my life being told by aghast MD’s that the migraines were all my own fault for creating ‘rebound’ migraines. I was astounded that they found it acceptable to ply me with up to 8 or more prescriptions to reduce the pain (which never worked), yet would not allow the only thing that worked, triptans. They even had me on prednisone for almost a YEAR, and tried to get me to increase to high doses of oxycontin which never worked in the first place.

Once I visited the regionally renown neurologist and migraine specialist, a guy who was making very good money being the ‘expert’. He was the go to guy, and if he couldn’t help you, no one could. He was rude, insulting, obtuse, and he told me if I continued taking daily triptans I would “die of a stroke within 2 years”. That was 7 years ago, but I can tell you the anxiety he caused me was incalculable.

The worst part of triptans is indeed the cost, I have spent many thousands on them even though I get them from a pharmacy in Mexico. I hate taking them, yet I’v never had any side effects, and my heart is very healthy.

My quality of life finally improved when I decided to stop trying – every day – to not take the triptans. When I finally decided this one drug couldn’t be worse than taking a litany of many others (and I tried everything else too, pain clinics, cognitive therapy, acupucture, cranio-sacral, massage, biofeedback, dietary changes, you name it).

I wish I didn’t have to take triptans. I hate paying for them, I don’t like taking any drug. However, without them I’d have no quality of life at all, so thanks for this post. Incidentally, I take up to 300 mg of imitrex a day (it is the cheapest of the triptans), spread out over the day in 50 mg increments.

Since I stopped worrying about taking them daily, and gave up all the other prescriptions, my visits to the ER (several times a year) have ceased, I haven’t had to go in over 3 years.

Continued..daily Triptan use makes a lot of sense to me, just need to convince my dr!

This is very interesting and exciting news as I have always been told not to use triptans more than 2 days per week because they cause MOH, just as all of the other medications do. I have chronic migraine and have been averaging 5 days of migraines per week. I’ve used imitrex since it first was introduced 20 years ago and it’s becoming less effective for me. I also use midrin, with Tylenol with codiene (limited amount), and zanaflex as rescue drugs. It’s not a very effective regimen but I can’t take anti-inflammatory meds or aspirin. I take preventive drugs also, which obviously, don’t seem to be working. I have tried and failed many preventive meds over the past 30 years, as well as biofeedback, acupuncture, Botox, gluten-free diet, physical therapy, and various supplements. I am starting to experiment with some of the other triptans now and I am thinking of trying Migralief since feverfew is one thing that I haven’t tried.
My doctor says I should only take pain meds 2 days per week but this is impossible with crushing migraines 5 days/week! Daily triptan

I would ask your doctor to provide you with the source of her information because as far as I know, there is no evidence that taking triptans daily at any age can cause a stroke or an MI. In fact, there is evidence to suggest that there is no increased risk.

I have had migraines mostly daily since age 11. I am currently 62 yo. I must say I have tried everything imaginable including eating gluten free, being almost addicted to opioids, and have tried every preventative ever prescribed. I lead a fairly normal life as I made this decision many years ago that migraines are not going to run my life. I took my first triptan in 1998; Zomig. It was a miracle. I have seen several great migraine MD’s. Many are published and the only thing that seems to work is zomig. I take it daily. Everyone is sure that this is a bad idea. I have a healthy heart, I am very active, and I have stopped any over the counter meds. My rescue med is Indocin supp. I fight with the insurance company yearly but I seem to convince them, (or my doctors do.)
I did see a recent specialist and she said because of my age, my migraines should be gone, but they are not. She really scared me and said I may have an ‘event; stroke or MI,) if I don’t stop taking triptans more than 2 days a week. This is a conundrum, what to do?

Yes, many insurance companies will approve larger amounts of triptan drugs. This usually requires a letter from the doctor describing the reason for a larger number of tablets, preventive drugs (including Botox) that have been tried, and the degree of disability that will result if the patient is not given a sufficient amount of the medication. Some insurers will not deny the larger amount, but will ask for a large copay ($50 is not unusual) for every 4 tablets they give you. This is harder to appeal because there has been no denial, but being persistent and becoming a pest sometimes pays off.

It often matters from a psychological point of view. I have some patients who have been told about the potential for rebound headaches and other side effects from triptan. These patients are very reluctant to take triptans daily. They often wait to take medicine as long as they can until the pain becomes severe, but they still end up taking a triptan every day. I usually tell them to stop worrying about the potential side effects (if they have a healthy heart) and take the medicine early or even preventively. This way they will have better pain relief, will stop living in a state of constant anxiety about their medication intake, and will have a much better quality of life.

My insurance company allows a three-month supply of 27 pills (9 a month). This is nowhere near enough to manage my migraines. I hate having to “ration” when I get to the end of the supply and deciding to use the much less effective Excedrin instead. Will insurance companies eventually approve a higher monthly quantity?

Why does it matter if triptans are taken daily for abortive use or for prevention?